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Recovery and Resiliency - Lee Thomas - TEDxDalhousieUJoint health resilience -
Protein is a fundamental macronutrient that is a critical building block of the human body and is essential to support the growth, development and recovery of muscles.
If you want your body to operate at its best, it needs ample amounts of protein. Protein is involved in one form or another in everything your body does.
We collaborated with registered dietitians and human performance specialists from elite professional sports teams to create a protein supplement of the highest quality for their athletes and you.
Recovery is a balanced blend of proteins and carbohydrates designed to fuel rapid recovery from strenuos workouts.
Recovery is intentionally designed to include a protein-to-carb ratio. The base of premium grass-fed whey isolate starts the muscle recovery and protein synthesis processes while L-glutamine and L-carnitine help support the repair and rebuilding of muscle tissue, reducing muscle soreness and promoting optimal muscle function.
Collagen Peptides. Collagen is the most abundant protein in the human body and is vital to the structural integrity of your tendons and ligaments, as well as your skin, muscles and bones.
Our Collagen Peptides is a meticulously formulated blend that goes beyond standard collagen offerings by combining bovine collagen, vitamin C, and FORTIGEL®.
This clinically researched formula delivers 15g of collagen in support of Type I, II and III collagen in the body resulting in improvements in both the amount and strength of collagen formed in the body. Magnesium Threonate. Magnesium Threonate supports brain health and normal cognitive function.
Magnesium plays a key role in sleep and daily supplementation has been shown to increase sleep time, sleep efficiency and melatonin. Zinc's benefits are well-supported by scientific research.
Studies have consistently demonstrated the essential role of zinc in immune function, cellular health, and antioxidant defense.
Zinc Picolinate, specifically, has been shown to have excellent bioavailability and absorption rates, making it an effective and reliable source of zinc.
While all products are designed to work synergistically, we recommend following the specific instructions for each product to maximize benefits. Definition: Effective collection and analysis of patient-reported outcomes by the provider or health plan, including measurement of health disparities; timely collection and use of alternative collection methods e.
Capability: Implement shared savings payment model. Definition: Participate in payment models which set a benchmark target for cost within a defined population, and evaluate performance based on whether the provider achieves the benchmark subject to quality, minimum savings rates, or other factors.
In this model, providers are not subject to any losses for failing to achieve the target, which allows for a lower-financial risk environment to gain experience in these types of arrangements. Capability: Implement pay-for-performance payment model. Definition: Participate in alternative payment models that provide incentives based on performance in quality, cost, access and other measures.
To the extent possible, work across health plans to standardize the measures used in these alternative payment models, and work with operational stakeholders to establish processes for tracking and monitoring performance on these measures. Include these measures in administrator and clinician goals.
Capability: Integrated financial and clinical team actively engaged to incorporate clinical perspectives with data outputs to identify insights and target performance improvement opportunities. Definition: Clinical and financial data are reviewed together to capture understanding of cost, utilization, quality, and outcomes relative to metric targets.
Definition: Begin participation in episodic payment arrangements that set payment for managing the care for a defined diagnosis or procedure across a preset time period.
Develop processes to analyze claims data to evaluate opportunities to reduce clinical variation within episodes. Develop clinical programs that are aligned to alternative payment models. Capability: Coordinated patient-centric partnerships that serve as foundation for multiple commercial and governmental payer products.
Definition: Applying promising practices identified from coordinated care delivery and incorporating into a standardized approach with payer products. Capability: Leverage interoperable data exchange.
Definition: May include the usage of a regional Health Information Exchange HIE or other tools that facilitate the exchange of multiple types and formats of data between organizations.
Capability: Leverage clinical natural language processing cNLP to optimize medical record data capture. Definition: Utilization of cNLP to assist with comprehensive clinical data capture and categorization to inform population health risk stratification, input to chronic disease registries, and identify care gaps.
Capability: Leverage claims system that accommodates alternative payment models APMs. Definition: Implementation and utilization of a claims system which can process payments beyond fee-for-service, without manual workarounds.
Capability: Implement electronic health records EHR. Definition: Implementation and usage of an EHR to capture medical records and other clinical data for usage in reporting. Capability: Leverage employer and administrative services only ASO reporting.
Definition: Develop reporting specifically for self-insured entities, such as employer groups, where the health plan serves in an ASO capacity. Reporting should provide insights on utilization trends and patterns, areas of high expenditures, common health conditions, and cost containment strategies.
Additional insights may be provided in areas such as employee engagement e. branded drugs. Capability: Develop inclusive and equitable medical policies. Definition: All policies include rationale for the mandate based on industry standards and evidence-based promising practices.
Capability: Coordinate clinical quality and performance metrics across governmental and commercial health plans enabling synergistic improvements in health outcomes.
Capability: Identify care management activities and stratification based on clinical, claims, social drivers, urgency of needs. Definition: Initial collaboration in development of patient plans of care that span the continuum of care, prioritize efforts, and support ongoing cross-functional communication on updates to support alignment.
Capability: Enable online appointment and resource scheduling. Definition: Giving patients the option to self-schedule appointments from a computer or mobile device to improve convenience, experience, and satisfaction.
Capability: Omni-channel communication including mobile and digital designed with cultural diversity. Definition: Focuses on offering and delivering a personalized and culturally sensitive communication experience using multiple communication tools including phone, email, mobile apps, and online platforms.
Capability: Administer wellness and preventative screenings. Definition: Used to screen for potential illnesses and maintenance of health. Capability: Development of a health equity plan. Definition: Includes engagement with community organizations to develop a list of priority activities, timelines, and responsibilities that addresses gaps voiced by community representatives with multiple community and state stakeholders.
Capability: Investment in digital community resource directories. Ideally, organizations create or leverage regional and national platforms that allow for referral monitoring and are continually updated with the latest information on available services and resources.
Capability: Interdisciplinary coordination and site of care. Definition: Deliberate collaboration between multiple health specialties to provide holistic approach to care. Focused attention on most appropriate level and site of care based on performance and cost containment strategies.
Integrated care leads to less confusion for the patient and better adherence and outcomes. Peter Walsh joined the Colorado Department of Health Care Policy and Financing as the Chief Medical Officer on December 1, Prior to joining HCPF, Dr. Walsh is an Aerospace Medicine Specialist, who provided primary care to aircrew and special operational personnel and their families during much of his year active duty career in the U.
Air Force. Upon retirement in he served as an Urgent Care Physician at the previous Memorial Health System in Colorado Springs between and and practiced at the Centura Center for Occupational Medicine in Colorado Springs, CO and Pueblo, CO between and His prior positions include serving as the Chief Medical Officer, South State Operating Group of Centura Health, Corporate Chief Medical Executive for Centura Health in Denver, Colorado, and the VP of Medical Affairs at St.
Francis Medical Center in Colorado Springs, Colorado. Walsh received his B. at the University of Southern California, his M. from the Medical College of Ohio in Toledo, Ohio, and a M. from Harvard School of Public Health. He completed his residency in Aerospace Medicine at the USAF School of Aerospace Medicine at Brooks AFB, Texas.
Ryan previously served as the clinical lead for the Massachusetts COVID Response Command Center. Prior to his time with Massachusetts state government, Ryan worked with multiple governments and health care systems globally, including as a technical adviser to the World Bank. Elisa Wrede is the project manager for primary care in the Office of the Secretary at the New Mexico Human Services Department.
She oversees the New Mexico Primary Care Council PCC , which is working toward revolutionizing primary care in New Mexico.
Her role includes creating primary care payment reforms in New Mexico Medicaid that move toward paying for quality and population health. The Center for Health Care Strategies selected New Mexico as one of five states to participate in a national learning collaborative to support approaches to advance health.
equity in primary care payment models. Elisa previously worked in community engagement and corporate social responsibility helping to connect communities with volunteers and resources through grants and sponsorship.
She enjoys thrifting, playing her mandolin, and creating art. Elisa lives in Santa Fe with her family and two cats. Learning stage, the organization can assess and evaluate health disparities impacting the population against a baseline. Investing stage, the organization can expand into baseline health disparities identification and provides and supports patients with access to community resources initiatives while successfully measuring outcomes.
Aligning stage, the organization supports alignment of multiple internal and community resources, supports patients in accessing resources, and continues monitoring ongoing health equity initiatives and disparities.
Transforming stage, the organization supports improved equity across all its components, supports community initiatives to improve access to clinical care and reduce the impediments to care, and demonstrates improved outcomes and access to care across all populations.
Supports an inclusive, equitable, and integrated care management framework that identifies opportunities to improve health outcomes for underserved populations.
Please note that the Health Equity Measurement Track, and specifically the Care Management subcomponent, has significant integration and dependencies with the Data and Infrastructure Measurement Track, as access to timely and accurate data is paramount to driving equitable care management and equity overall.
Supports capturing and addressing social determinants of health concerns, and partnering with the community in shaping equity investments, interventions, and measurement outcomes to optimize equitable, high-value access to care. Supports the activation and empowerment of members and patients to improve their own care using a range of communication mediums e.
Capability: Develop regional collaboration approach to drive alternative payment model movement. Capability: Build qualitative indicators for multi-stakeholder network success.
Definition: Identify success indicators and set short-and long-term goals. Capability: Conduct community health needs assessment focused on historically underserved populations with complex needs.
Definition: Targeted assessment focused on historically underserved populations with complex needs in the community to identify potential gaps and required interventions.
Supports the organization of stakeholders to partner, collaborate, and integrate on accountable care approaches to drive alternative payment model movement. Capability: Develop network development strategy to improve adequacy gaps.
Definition: Create a strategy and actionable interventions to improve network adequacy using identified gaps from provider network adequacy analysis.
Transforming stage supports transparent multi-stakeholder alignment and forward-thinking infrastructure that advances accountable care models and arrangements. Aligning stage s upports multi-stakeholder participation in advancing accountable care models and arrangements with measurable progress.
Learning stage supports identifying opportunities available to educate multiple stakeholders on the existing accountable care landscape. Capability: Enhanced usage of enterprise software.
Definition: Utilization of enterprise software such as data warehouses to capture, store, and analyze multiple types of data at once e.
Capability: EHR incorporates digital integration with community and social services. Definition: Ability of EHR to capture and communicate with community or social services tools and systems for sharing of data and referrals. Capability: Implement enterprise software approach.
Sub-capability: Insights identified in employer and ASO reports utilized for improved quality, outcomes, and utilization.
Capability: Analytics rules engine with multidimensional identification and stratification modeling. Definition: Building on the initial Analytics Rules Engine to utilize multiple data sources e. Capability: Leverage analytics rules engine.
Definition: Consumes raw data to apply and execute a defined logical rule set to create meaningful output that can be further analyzed to develop actionable next steps. Capability: Implement singular source of data capture. Definition: Relevant source systems used to capture important data elements have been identified and are under the purview of the data management structure.
Instances where the same data is being captured in multiple locations e. Capability: Ongoing monitoring of low-value care. Capability: Leverage quality standards and benchmarks for top performance.
Definition: Using top performance benchmarks and quality standards to show gaps in performance and to align quality improvement plan targets. Capability: Utilizes insights from reporting to support provider specific and system improvements. Definition: Application of blinded quality performance results comparisons between individual providers to drive provider-specific process improvements.
Capability: Leverage gold carding in utilization management. Definition: Develop artificial intelligence AI -assisted utilization management programs and gold carding standards of performance and allow top performing practices a reprieve from authorization submission to increase clinical review efficiency and accuracy, as well as reduce administrative burden.
Definition: Ensuring clinical stakeholders participate in outcomes discussions to determine interventions and next steps.
Capability: Develop approach to address low-value care. Definition: Approach may include focus on appropriateness of care that is anchored in improving outcomes evidence-based promising practices.
Capability: Enhancements to utilization management to reduce barriers to care. Capability: Develop medical policy review approach.
Capability: Develop key performance indicator management and alignment. Definition: Aligning on what key performance indicators the organization will focus on as well as tools to monitor results with actionable interventions. Supports advancing health IT ecosystem with progressive data exchange and communication across multiple stakeholders.
Capability: Encourage provider-specific reporting incorporating quality, utilization, financial outcomes, and benchmark comparisons. Capability: Engage and collaborate with provider leadership in reconciling perceived conflicts between clinical quality and governmental and health plan performance quality metrics.
Transforming stage supports advanced data collection, sharing infrastructure, and activities to measure progress on payment reform, quality, affordability, and equity. Investing stage supports investment in improved data collection, analytics, and measurement outcomes.
Learning stage supports development of data management and governance necessary for infrastructure to support analytics and insights development. Supports capturing and benchmarking quality reporting metrics across populations to monitor the progress and success of quality improvement initiatives or the need for additional quality intervention efforts.
Transforming stage supports using standardized system-wide processes and tools to predict populations with gaps in care needs to drive interventions and improve patient experience as well as drive high-quality care and improved outcomes for all.
Learning stage supports recognition of standard quality metrics and current state of quality performance. Capability: Manage financial reconciliation. Definition: Process of making financial payments consistent with payment methodology, typically at the end of a defined period, e.
Capability: Development of contract management platform. Definition: System to organize, track, and monitor contracting terms, performance metrics, and payment methodology across contracts with payers and providers. Capability: Reporting of monitor targets and performance. Capability: Enhanced physician education and coaching including provider network collaboration.
Definition: Intersects with Multi-Stakeholder Alignment and Design Measurement Track. An important component of contract performance is first understanding the value proposition of accountable care, and educating physicians in the tenets of accountable care e.
Capability: Develop provider dashboards and portals. Definition: Reporting tools displaying defined provider specific metrics and key performance indicators often accessed through a secure website. Capability: Provide administrative and financial support. Definition: Support resources available to capture and track alternative payment methodologies across commercial and governmental businesses.
Capability: Enhance product and price transparency episode-level pricing. Definition: Share pricing for episode level products and services per governmental standards and in a manner that enables informed decision-making between patient and provider.
Transforming stage supports understanding of the impact population-based payment methodologies have on organizational financial performance and health. Aligning stage supports increasingly advanced payment models which better align incentives of providers to address cost and quality outcomes to improve affordability.
Investing stage supports alternative payment model framework for outcome reimbursement. Daniel Tsai, M. He leads CMCS in addressing disparities in health equity and serving the needs of individuals and families who rely on these essential programs.
His six-year tenure focused on building a robust and sustainable Medicaid program to ensure equitable coverage and improve health care delivery for two million individuals and families in the state.
Daniel also helped lead Massachusetts Medicaid through its most significant restructuring since the s through its landmark Medicaid waiver. Under these reforms, MassHealth implemented one of the most at-scale shifts to value-based care in the nation.
Through the waiver, MassHealth also launched a unique program committing significant investments for nutritional and housing supports to address the social determinants of health for high-cost, at-risk individuals.
In addition, during his tenure, the agency made critical investments in strengthening community health centers, behavioral health, and home- and community-based services.
Having worked closely with organizations across almost every aspect of health care, including a diverse range of Medicaid programs and provider organizations, Daniel brings extensive experience across Medicaid, Medicare, and health care stakeholders.
He has worked with stakeholders to design and implement innovative models for health care coverage, delivery, and payment. Daniel earned a Bachelor of Arts in applied mathematics and economics from Harvard University, summa cum laude. Sub-capability: Analytics reporting includes insights generated from the addition of clinical, financial, and business considerations.
Sub-capability: Value based contract insights identified across sub-populations utilized to improve quality, outcomes, utilization, and performance.
gov health insurance marketplace. A former policy official who played a key role in guiding the Affordable Care Act ACA through passage and implementation, Brooks-LaSure has decades of experience in the federal government, on Capitol Hill, and in the private sector.
Earlier in her career, Brooks-LaSure assisted House leaders in passing several healthcare laws, including the Medicare Improvements for Patients and Providers Act of and the ACA, as part of the Democratic staff for the U. Brooks-LaSure began her career as a program examiner and lead Medicaid analyst for the Office of Management and Budget, coordinating Medicaid policy development for the health financing branch.
Elizabeth Fowler, Ph. Liz was special assistant to President Obama on healthcare and economic policy at the National Economic Council. In , she was chief health counsel to Senate Finance Committee Chair, Senator Max Baucus D-MT , where she played a critical role developing the Senate version of the Affordable Care Act.
She also played a key role drafting the Medicare Prescription Drug, Improvement and Modernization Act MMA. Liz has over 25 years of experience in health policy and health services research. from the Johns Hopkins Bloomberg School of Public Health, where her research focused on risk adjustment, and a law degree J.
from the University of Minnesota. She is admitted to the bar in Maryland, the District of Columbia, and the U. Supreme Court. Liz is a Fellow of the inaugural class of the Aspen Health Innovators Fellowship and a member of the Aspen Global Leadership Network.
Jeff Micklos, J. Jeff began his career as a litigator and regulatory counsel for the Health Care Financing Administration of the U.
Department of Health and Human Services. Additionally, Jeff served in the Office of General Counsel of the Social Security Administration. He received a Bachelor of Arts from Villanova University. He resides in Washington, D. Capability: Cohesive digital referral and management platform.
Judy Zerzan-Thul is the Chief Medical Officer at Washington State Health Care Authority, Co-Chair of the LAN Executive Forum, and a general internal medicine physician.
Zerzan-Thul specializes in value-based payment models and healthcare financing. Prior to her role as the Chief Medical Officer for Washington State, Dr.
Zerzan-Thul was the Chief Medical Officer at the Colorado Department of Health Care Policy and Financing. She led the implementation of the Affordable Care Act ACA in Colorado. She has extensive experience designing and implementing health plans and benefits for Medicaid programs.
Zerzan-Thul holds a Doctor of Medicine from Oregon Health and Science University and received a Master of Public Health in Health Policy and Administration from the University of North Carolina. From to , she was a non-residential Health and Aging Policy Fellow for the office of Senator John D.
Rockefeller IV of West Virginia, where she supported public policy for the Affordable Care Act. Nedhari brings more than 18 years of experience in community organizing, reproductive justice, and program development.
She is a mother, licensed Certified Professional Midwife, Family Counselor, and the Co-founding Executive Director of Mamatoto Village. Aza is a fiercely dedicated woman who believes that by promoting a framework of justice, the reduction of barriers in maternal and child health begins to dissipate; giving rise to healthy individuals, healthy families, and healthy communities.
Aza is pursuing her Doctorate in Human Services with a concentration in Organizational Leadership and Management with an eye towards the sustainability of Black led organizations and cultivating innovative models of perinatal care delivery and workforce development.
Timothy P. McNeill also serves as the co-chair of the Partnership to Align Social Care. The Partnership to Align Social Care is a multi-sectoral group of health plans, health systems, community-based organizations and Government liaisons that work together to identify and address priority issues that are essential to a fully aligned health and social care system that incorporates the vital voice of the community.
McNeill has started or expanded multiple sustainable health programs including two Medicare Shared Savings Program MSSP ACOs, an IPA made up of FQHCs and independent physicians, a network of community-based free clinics, managed the operations of a network of Federally Qualified Health Centers, and established multiple regional networks to deliver Long-Term Services and Supports, contracting with MCOs, in support of State Medicaid Waiver implementation.
McNeill is also a retired U. Navy Nurse Corps Officer. Sam oversees food programs and systems change work at Reinvestment Partners, an anti-poverty non-profit based in Durham NC.
Before joining Reinvestment Partners, Sam was the program evaluator and food systems lead for a SNAP-Education program at NC State University. She received an MS in Food Policy and Applied Nutrition from the Friedman School of Nutrition Science and Policy, and she brings a critical perspective to food work.
Joseph Strickland resides in southeast Alabama having lived in the Wiregrass region for most of his life. He holds a Master of Science degree from Troy University. He is passionate about developing and implementing quality LTSS: Long Term Services and Supports, for the Aging population.
He was instrumental in developing a model of delivery for LTSS case management that led to successful contracting with a managed care organization. In addition, Mr. Strickland served as lead developer for a case management software system used by all AAAs in support of their Medicaid Waiver case management activities.
The development and implementation of the case management system was pivotal in the Alabama AAA effort to demonstrate proficiency in case management activities as well as provide a platform to manage programs, staff, and enrollees.
In addition to his work in developing and managing the case management system used by the Alabama AAA network, Mr. Strickland also serves as the lead for organization efforts focused on National Committee for Quality Assurance NCQA Accreditation standards for CM-LTSS.
SARCOA was the first AAA in Alabama to become Accredited by the National Committee for Quality Assurance for CM-LTSS and was instrumental in leading all Alabama AAAs in their efforts to become accredited.
Alice Hm Chen, MD, MPH, serves as Chief Health Officer CHO for Centene Corporation. Prior to joining Centene, Dr. Chen was also a professor of medicine at the University of California San Francisco School of Medicine, based at the Zuckerberg San Francisco General Hospital, where she served as its Chief Integration Officer and founding director of the eConsult program.
Chen received a Bachelor of Science in Environmental Biology from Yale University and has a Doctor of Medicine from the Stanford University School of Medicine.
She also has a Master of Public Health in Health Care Management and Policy from Harvard School of Public Health. A primary care internist by training, she provides clinical care at Zuckerberg San Francisco General Hospital. Since , Leah Binder, M.
Leapfrog represents employers and other purchasers of health care calling for improved safety and quality in hospitals. She is a regular contributor to Forbes. com, Harvard Business Review, and other publications and is consistently cited among the most influential people and top women in health care.
Through annual surveys, The Leapfrog Group collects data from hospitals and ambulatory surgery centers on the quality of care.
Leapfrog also grades hospitals on how safe they are, a bold initiative that experts estimate has saved over 40, lives a year since Before joining Leapfrog, Leah was vice president for a nationally noted rural health system in Farmington, Maine.
Prior to that, she served as a senior policy advisor in the New York City Office of the Mayor. She started her career at the National League for Nursing. She lives in the Washington, D.
Rhonda M. Medows, M. Medows has extensive health care industry experience in both the private sector and government health programs including Medicare and Medicaid.
She formally served on the U. Department of Health and Human Services Physician-Focused Payment Model Technical Advisory Council focused on developing new alternative payment models. Prior to joining Providence, she served as an executive vice president and chief medical officer of UnitedHealth Group.
While there, she led quality management and improvement initiatives and provided leadership and oversight of efforts to improve clinical quality and operational excellence. Until March , Dr. Medows also served as secretary of the Florida Agency for Health Care Administrative, the state agency responsible for the Medicaid and SCHIP programs, health facility regulation, managed care quality, health information exchange, and public policy development.
She practiced medicine at Mayo Clinic and is board certified in family medicine. She is also a fellow of the American Academy of Family Physicians. She is a national health and health care equity policy and advocacy thought leader with 25 years of experience advancing equal opportunity for women and families of color, and almost 20 years advocating for increased health care access and improved quality of care for underserved communities.
Sinsi is deeply committed to transforming our health care system to meet the needs of our rapidly evolving nation so we can all thrive together. She believes that our future prosperity depends on ensuring our health care system routinely provides excellent, comprehensive, culturally centered and affordable care for every single person, family and community, and that this requires the dismantling of structural inequities including racism, sexism, ableism, homophobia, transphobia, xenophobia and religious bigotry.
Sinsi is a recognized leader in the national health equity movement, a sought-after strategic advisor and a dynamic, inspiring speaker. She has presented at national events across the country and served on numerous advisory committees for organizations including the National Academy of Medicine, the National Committee for Quality Assurance, the Patient Centered Outcomes Research Institute, the Robert Wood Johnson Foundation, the National Center for Complex Health and Social Needs and the American Association of Pediatrics.
She has published extensively and has appeared in national and state level English and Spanish television, radio and print media. Prior to that, she advised and represented two governors of Puerto Rico on federal health and human services policies, and she worked for the Service Employees International Union SEIU as a senior health policy analyst and national campaign coordinator for their Healthcare Equality Project campaign to enact the Affordable Care Act.
Born in San Juan, Puerto Rico, Sinsi is bilingual and bicultural. She earned an A. She lives in Fairfax with her husband, teenage son and two rescue dogs. She loves sci-fi, board games and expressing her love for family and friends by feeding them. Purva Rawal, Ph. Previously, she was a principal at CapView Strategies, where she developed evidence-based public policy and business strategies for providers, health systems, life sciences companies, and coalitions.
She also conducted policy research on health system transformation and sustainability issues. She is also an adjunct assistant professor at Georgetown University. In this study we sought to identify whether pre-operative resilience is predictive of 3-month postoperative outcomes after adjusting for pain catastrophizing and other covariates.
Patients undergoing TKA between January and November were included in this longitudinal cohort study. Demographics and questionnaires [Brief Resilience Scale BRS , Pain Catastrophizing Scale PCS , Knee injury and Osteoarthritis Outcome Score, Junior KOOS, JR. and Patient-Reported Outcomes Measurement Information System Physical and Mental Health PROMIS PH and MH, respectively ] were collected preoperatively and 3 months postoperatively.
Multivariable regression was used to test associations of preoperative BRS with postoperative outcomes, adjusting for PCS and other patient-level sociodemographic and clinical characteristics. The study cohort included patients with a median age of Fifty-three percent of patients were women and Our prospective cohort study suggests that resilience predicts postoperative knee function and general physical health in patients undergoing TKA.
Exploring interventions that address preoperative mental health and resilience more specifically may improve self-reported physical function outcomes of patients undergoing TKA. Total knee arthroplasty TKA is a procedure that is currently performed over , times annually in the United States [ 1 ].
Common indications for TKA include pain, disability, impact on daily function, and arthritic deformity of the knee such as osteoarthritis, rheumatoid arthritis, and other forms of arthritic deformity [ 2 ]. Typically, before surgery is considered, physicians will initiate a trial period of conservative therapies [ 4 ].
These can vary based on the type of arthritic insult, but can include weight loss, aerobic and anaerobic exercise, nonsteroidal anti-inflammatory drugs, and a variety of other treatments.
Consideration of psychological interventions is not common and are not standard practice even preoperatively despite evidence to suggest their potential benefit.
Despite pain reduction and mobility improvements from TKA, research has indicated that patients undergoing TKA with higher levels of preoperative pain catastrophizing experience lower levels of function following surgery [ 5 ].
Similar to depression and anxiety, pain catastrophizing is a negative psychological construct that has received attention in orthopedics and other fields. In chronic pain studies, pain catastrophizing has been cited as a vulnerability factor in the pathway to physical functioning whereas resilience mechanisms are thought to represent coping responses [ 6 ].
Additionally, a recent systematic review conducted in patients with TKA demonstrated a relationship between pain catastrophizing and increased chronic pain [ 7 ]. Higher levels of pain catastrophizing have also been linked to poor function [ 8 ], more postoperative pain [ 9 ], and more nighttime pain [ 9 ] consistently in other studies.
Unlike pain catastrophizing, resilience is a positive psychological construct that has recently gained more attention in orthopedics. This construct encompasses positive environmental and emotional characteristics that allow a person to endure adversity [ 10 ].
Optimism, independence, and protective family and community networks are also used to define this construct [ 11 , 12 ]. Psychological resilience is inversely correlated with depression and facilitates adaptation to distressing events, such as psychological and physical trauma [ 13 , 14 , 15 ].
Patients who have suffered traumatic physical injuries brain, spinal cord, and musculoskeletal and engage in resilience-building programs return to work in a shorter amount of time and have improved self-efficacy [ 16 ].
Further, higher resilience may predict reductions in pain catastrophizing in chronic pain patients over time [ 17 ]. Only a few studies in the arthroplasty literature have attempted to define the association between resilience and post-surgical outcomes, specifically focusing on knee function and quality of life [ 18 , 19 , 20 ] with conflicting findings to date.
Research on the association of resilience and outcomes specific to TKA is sparse. Further, it is unclear if stronger positive resilience would be associated with better post-surgical outcomes after accounting for negative psychological constructs such as pain catastrophizing.
Clearly delineating these relationships could play an important role in how clinicians optimize patients prior to TKA. To more clearly define the relationship between resilience and postoperative outcomes, we conducted a prospective cohort study to investigate whether preoperative resilience is predictive of postoperative knee function, general physical health, and general mental health 3 months after TKA, and whether any association identified would persist after adjusting for pain catastrophizing and patient sociodemographic and clinical characteristics.
These two psychological constructs are often studied independent of one another and to our knowledge, this is the first study of patients with TKA to examine them together. In this prospective cohort study, patients were recruited from an outpatient orthopedic clinic of a large academic medical center from January to November Approval from the Institutional Review Board IRB was obtained prior to initiation of this study.
Patient information was collected and stored within REDCap, a secure, web-based application platform [ 21 ]. Prior to a clinic appointment, the patient's electronic medical record was pre-screened for study eligibility.
Following consent for surgery by one of four joint replacement surgeons in the outpatient orthopedic clinic, patients were informed of the opportunity to participate in a study of outcomes for patients undergoing TKA.
If interested and study eligible, the study was explained, and the patient consented prior to leaving the clinic. Patients were eligible if they were able to read and write in English, able to provide written informed consent, 35—85 years old, and approved to undergo unilateral TKA by an orthopedic surgeon.
We chose not to include patients younger than 35 years in order to select against patients with knee pathology related to congenital, traumatic, and developmental origins [ 22 ]. Patients were further excluded if their baseline measures were incomplete.
On the day of surgery, patients were treated preoperatively with regional anesthesia to include a spinal block in addition to one or two additional peripheral nerve blocks. Postoperatively, in addition to the regional anesthesia blocks, patients received pain medications e. Patients were discharged on a combination of these medications.
For postoperative therapy, patients were weight-bearing as tolerated and began therapy on postoperative day zero. Aggressive range of motion was discouraged until at least 2-weeks post-surgery, allowing swelling to dissipate and the wound to heal.
Following study enrollment, patients completed a demographics survey capturing age, sex, race, ethnicity, marital status, employment status, years of education, and insurance type. The Pain NRS is a single item response value on a scale of 0—10 with higher scores indicating increased intensity [ 23 ].
At baseline, patients were asked to complete four questionnaires. These questionnaires were repeated at 3-months following surgery. At the postoperative visit, a study investigator would systematically attempt to meet patients in person at their scheduled clinic visit with the operating provider if scheduled.
If no appointment was scheduled, study investigators would utilize email, then a phone call, which was followed by a mailed survey packet if no contact was made. All follow-up data were obtained no more than 1 week before or after each scheduled 3-month follow-up time point.
When evaluating patient-reported function and pain, studies have shown that clinical services and the majority of change occurs within the 3-month postoperative period [ 24 , 26 ].
Comorbidities have been shown to influence functional outcomes of following TKA. To account for these factors, baseline clinical information was collected via retrospective chart review of the electronic medical record.
These data included a documented history or clinical diagnosis of depression, anxiety, and back pain with specific category for low back pain. Classification for a history or clinical diagnosis of diabetes for this study did not include gestational diabetes, glycemic disorders e.
Finally, patients were considered to have a history of cardiovascular disease if there was documentation of a history or clinical diagnosis of coronary artery disease, myocardial infarction, stroke, arrhythmia, valvular disease, or heart failure [ 24 ]. revision , previous TKA on the contralateral side, diagnostic criteria knee arthritis etiology , smoking status, and pack years were also collected in the retrospective chart review.
Pain catastrophizing scores were calculated using the Pain Catastrophizing Scale PCS [ 5 , 26 ]. This scale is useful because it analyzes recent pain-related thoughts.
The PCS score is obtained by summing the values for all 13 items within the measure. Scores range from 0 to 52 and higher scores indicate increased pain catastrophizing. Patient resilience scores were calculated using the Brief Resilience Scale BRS [ 11 ].
This scale represents the concept of resilience most directly, whereas other scales are more reflective of the personality traits and strategies that patients utilize in order to increase their resilience. Items on the BRS are scored on a 5-point Likert Scale.
The total BRS score range 1—5 is an average of all of the items after reverse coding 3 items with higher scores indicating more resilient individuals. The following standardized instruments were utilized to collect patient-reported information regarding health:.
The KOOS, JR. The KOOS Jr. questions capture patient opinions up to 1 week prior to survey administration. Scores are transformed to a scale ranging from 0 to , with higher scores representing better knee function.
The test has been validated against legacy measures, the Western Ontario and McMaster Universities Osteoarthritis Index WOMAC and full-length KOOS, which take considerably longer to administer [ 27 ]. This measure is also recommended for use with patients undergoing TKA in the perioperative period by the Centers for Medicare and Medicaid under the Comprehensive Care for Joint Replacement Model [ 28 ].
This instrument utilizes 10 items to provide an assessment of different components of patient quality-of-life. T-score tables are used for comparison of the physical and mental health raw scores to the general population [ 31 ]. After conversion, 50 is the mean, and converted t-scores that are 10 points below or above this number are understood to be 1 standard deviation away from the mean [ 30 ].
This allows for comparison of the mental and physical health scores to the general population with higher scores indicating better health. A sample size of patients, achieves at least The variable tested can be adjusted for up to an additional 15 independent variable s.
An effect size of 0. Cohen's f 2 interpretation: 0. Thus, we were adequately powered to detect a small to medium effect size. Additional patients were recruited assuming that some patients would be lost to follow-up [ 32 ]. Continuous variables are presented using the mean and standard deviation SD or median with 25th and 75th percentiles dependent on data distribution.
Normality of continuous data was assessed using the Shapiro—Wilk test. Categorical variables are described using counts and percentages of non-missing data.
Certain categorical variables were simplified into common subgroups to reduce categories and increase power. Correlations among continuous preoperative variables were determined by calculating Pearson correlation coefficients to determine the linear relationship.
Multivariable linear regression models were constructed for each 3-month postoperative primary outcome, including KOOS and PROMIS GH and MH.
The goal was to describe the independent association between each of resilience and pain catastrophizing and the outcome variable of interest.
Based on our predetermined data collection procedures we anticipated the number of missing patients would be low. Therefore, we constructed three multivariable models for knee function, general physical health, and general mental health using only complete cases. Preoperative covariates were chosen for each of three models using univariable linear regression analyses to determine the relationship of each preoperative variable described in Table 1 to each outcome.
Therefore, covariates for each model vary. This cutoff was selected to increase chances of including predictors in each final model that most appropriately explain each outcome in this cohort.
Final models were assessed for multicollinearity using the variance inflation factor with a cutoff of 3. Assumptions for multiple regression were met for each outcome i. Pairwise differences within subject were calculated for baseline versus 3-month measurements for each outcome.
The significance of each difference was tested using the Wilcoxon sign rank test for paired comparisons. Analyses were conducted using RStudio [ 35 ]. A total of patients with upcoming clinic visits for surgery evaluation were screened in clinic based on chart review of eligibility criteria.
Of those eligible patients, candidates were excluded from inclusion or declined to participate based on rationale provided in Fig. Of eligible subjects, consented to participate; however, following consent, 11 patients were administratively withdrawn because of the change in their eligibility due to surgery Fig.
The median number of days that baseline assessments were completed before surgery was 15 days Q1—Q3: Overall, Of the patients included in analyses, the median age was Additionally, A history of diabetes and low back pain were reported in Baseline measures of pain catastrophizing, resilience, pain, and general health are also included in Table 1 Descriptive summaries of 3-month postoperative measures are included as Additional file 1 : Table S1.
Correlations for baseline psychological variables with concurrent health and function measures are presented in Table 2. All correlations for pain catastrophizing and resilience across health and function measures at baseline were significant.
Pain catastrophizing was negatively correlated with knee function, and general physical and mental health, while resilience was positively correlated with knee function and general physical and mental health prior to TKA. Simple linear regression and adjusted multiple variable regression models were used to determine whether baseline resilience was associated with knee function and general physical and mental health Table 3.
The full multiple regression models are displayed in Additional file 2 : Table S2, Additional file 3 : Table S3, and Additional file 4 : Table S4 as additional files. In the current study, we investigated the association between preoperative resilience and postoperative knee function and general health among patients undergoing TKA.
The association has not been widely explored in this patient population and to-date has not accounted for a known negative psychological construct, pain catastrophizing.
We found preoperative resilience was positively correlated with preoperative knee function and general health.
Importantly, our findings suggest that baseline resilience was predictive of 3-month knee function and general physical health and the significant association persisted after adjusting for pain catastrophizing and other patient covariates.
This positive psychological construct may be an important area of focus for future intervention in support of optimizing patient outcomes after TKA. Few studies of patients with TKA have explored resilience and postoperative outcomes and comparisons are limited due to differences in populations studied.
Our findings specific to patients with TKA demonstrated a statistically significant association between resilience and physical function; clinical significance was marginal as in previous studies [ 27 , 36 ].
Rebagliati et al. Though the study found no relationship between resilience measured by the Resilience Scale [ 37 ] and functional independence, the number of patients with knee surgery in this cohort was unspecified which limits and our ability to compare findings. A second study by this research group using the same resilience scale found that the level of presurgical resilience did not relate to functional independence for patients who had undergone elective joint replacement surgery [ 19 ].
This study of 80 patients who underwent joint replacement due to fracture concluded that patients who were less resilient when measured preoperatively were less likely to be functionally independent post-operatively; however only seven of the 80 who participated in the study had TKA and other baseline characteristics were not reported for patients with TKA versus THA.
In a recent study, Magaldi et al. but was associated with PROMIS physical health and mental health scores at 3-month and month follow-up. We hypothesize that our 3-month findings differ because we adjusted for pain catastrophizing in the current study which has a solid foundation of evidence for its influence on outcomes after TKA.
Based on our findings, we also postulate that patients with positive perceptions of their recovery process are able to handle the mental and physical stressors of surgery better than those with negative perceptions. Their opinions of recovery are likely based on previous adverse experiences, daily recovery progress, as well as traits that cumulatively guide the patient toward specific emotional and behavioral responses [ 17 , 38 ].
A patient who believes they are resilient will likely have higher levels of self-efficacy and will be more determined to complete what they perceive to be difficult physical tasks following surgery [ 40 ]. Alternatively, these resilient patients may not view surgery as an insurmountable obstacle, believing that the process of recovery is simply part of a necessary routine [ 6 ].
Furthermore, resilient patients may have a more positive evaluation of their perceived function during the recovery process because they self-identify as resilient patients, necessitating an equivalent self-evaluation to prevent cognitive dissonance. Finally, these resilient patients may also have social support networks that positively influence their progress perioperatively [ 38 ].
The relationship between pain catastrophizing and postoperative knee function, specifically in persons with TKA has received much attention over the last 2 decades. Three studies have found significant relationships between pain catastrophizing and function as measured by the WOMAC knee function subscale and postoperative function during follow-up as early as 6-weeks [ 5 ], 6-months [ 41 ], and 1-year [ 42 ] after adjustment.
In the current study, pain catastrophizing was negatively correlated with knee function and the PROMIS general health assessments. This is the first study we are aware of to analyze pain catastrophizing and associations with PROMIS physical health and mental health components.
We used this as an important signal of influence on recovery and why pain catastrophizing should be adjusted for in cohort studies examining outcomes of patients after TKA.
Considering the evidence to-date regarding psychological health and the relationship with outcomes after TKA, we suggest that further research is warranted in this field to elicit other key factors influencing functional recovery [ 44 , 45 , 46 , 47 ].
As suggested in recent literature, the broader understanding of the patient experience beyond negative psychosocial factors may hold the key to eliciting modifiable risk factors for patients undergoing TKA [ 39 ]. The current study is powerful because it highlights a rarely assessed concept that has potential for integration into future multimodal predictions tools for outcomes related to TKA [ 39 ].
In addition to defining the mechanisms behind the relationships between resilience and function as presented above, additional research in this area can also expand on the role of new psychosocial variables in the context of patient satisfaction in an increasingly patient-centered and patient-evaluated health care system.
In addition to the development of new preoperative tools, future directions in the field may target perioperative interventions that address key psychological constructs.
Two recent studies sought to improve functional outcomes in pain catastrophizing patients undergoing TKA using pain coping skills training [ 48 ] and cognitive behavioral therapy [ 49 ]; however, neither study was able to demonstrate that the selected interventions were superior to usual care.
To our knowledge, there are no studies in the arthroplasty literature that have tested interventions for patients with low resilience in an effort to improve postoperative function, general health or quality of life.
The current study is limited mostly by factors which were related to the most efficient and practical methods of collecting data from a prospective patient cohort in this academic medical center [ 50 , 51 ]. Patients were excluded based on English written or verbal proficiency.
Standardized measures were not available in the various languages present in this geography and interpreters were not available to study staff for each data collection time point, necessitating this limitation to generalizability.
Neither the prospective data collection or electronic medical record included duration of the disease or stage of the disease e.
Additionally, although patients were generally managed with pain medications under similar drug classes, the postoperative regimens for individual patients may have varied outside of the hospital setting. This study also has strengths that should be considered.
Enrollment was conducted primarily by the same individual, which contributes to the consistency of delivering study details, answering patient questions and obtaining consent. All patients provided complete contact information email address, phone number, and mailing addresses upon enrolling in the study which facilitated subsequent data collection.
Patients in the study were screened consecutively to limit selection bias. Additionally, the patients of four providers within the practice were utilized in order to increase generalization of the results. Investigators made an effort to limit unmeasured confounding by considering other variables available in the medical record that may influence associations.
Rheumatoid arthritis Food intolerances in sports an inflammatory, chronic and gealth disease Treatment options available causes joint damage and can lead to resilirnce disability. Patients with chronic and debilitating diseases resillience as arthritis need to halth to Joinh new reality. Joint health resilience changes may have less impact on patients with greater self-efficacy and resilience. Psychosocial factors influence the quality of life QoL of these patients, so the aim of this study was to assess resilience in this population and its relationship with pain, functional capacity and disease activity. This is a cross-sectional study carried out with patients at a medical specialties clinic, using a sociodemographic, a clinical-laboratory, a health assessment, a disease activity score questionnaires and the Wagnild and Young Resilience Scale. Pain was classified as severe by The resilience ofHealth and Reailience of Life Outcomes haelth Treatment options available reesilience, Article Growing Oranges at Home Cite this article. Metrics resiilience.
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Demographics and resilince [Brief Resilience Scale BRS healtg, Pain Catastrophizing Scale PCSKnee injury and Osteoarthritis Outcome Score, Sustainable nutrition choices KOOS, JR.
and Patient-Reported Reeilience Measurement Heaalth System Physical and Mental Resiliene PROMIS Personal glucose monitor and MH, respectively ] were collected preoperatively and 3 months postoperatively.
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Joing resilience resiloence inversely Treatment options available with depression and facilitates adaptation gealth distressing events, such resi,ience psychological and physical trauma [ 1314 resilidnce, 15 ]. Patients who have suffered traumatic desilience injuries Omega- for overall well-being, spinal cord, and Joknt and engage in resilience-building resilkence return to work in a resklience amount of time and have improved self-efficacy [ 16 ].
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Clearly delineating these relationships could play an important role in how clinicians optimize patients prior to TKA. To more clearly define the relationship between resilience and postoperative outcomes, we conducted a prospective cohort study to investigate whether preoperative resilience is predictive of postoperative knee function, general physical health, and general mental health 3 months after TKA, and whether any association identified would persist after adjusting for pain catastrophizing and patient sociodemographic and clinical characteristics.
These two psychological constructs are often studied independent of one another and to our knowledge, this is the first study of patients with TKA to examine them together.
In this prospective cohort study, patients were recruited from an outpatient orthopedic clinic of a large academic medical center from January to November Approval from the Institutional Review Board IRB was obtained prior to initiation of this study.
Patient information was collected and stored within REDCap, a secure, web-based application platform [ 21 ]. Prior to a clinic appointment, the patient's electronic medical record was pre-screened for study eligibility.
Following consent for surgery by one of four joint replacement surgeons in the outpatient orthopedic clinic, patients were informed of the opportunity to participate in a study of outcomes for patients undergoing TKA. If interested and study eligible, the study was explained, and the patient consented prior to leaving the clinic.
Patients were eligible if they were able to read and write in English, able to provide written informed consent, 35—85 years old, and approved to undergo unilateral TKA by an orthopedic surgeon. We chose not to include patients younger than 35 years in order to select against patients with knee pathology related to congenital, traumatic, and developmental origins [ 22 ].
Patients were further excluded if their baseline measures were incomplete. On the day of surgery, patients were treated preoperatively with regional anesthesia to include a spinal block in addition to one or two additional peripheral nerve blocks.
Postoperatively, in addition to the regional anesthesia blocks, patients received pain medications e. Patients were discharged on a combination of these medications.
For postoperative therapy, patients were weight-bearing as tolerated and began therapy on postoperative day zero. Aggressive range of motion was discouraged until at least 2-weeks post-surgery, allowing swelling to dissipate and the wound to heal.
Following study enrollment, patients completed a demographics survey capturing age, sex, race, ethnicity, marital status, employment status, years of education, and insurance type. The Pain NRS is a single item response value on a scale of 0—10 with higher scores indicating increased intensity [ 23 ].
At baseline, patients were asked to complete four questionnaires. These questionnaires were repeated at 3-months following surgery. At the postoperative visit, a study investigator would systematically attempt to meet patients in person at their scheduled clinic visit with the operating provider if scheduled.
If no appointment was scheduled, study investigators would utilize email, then a phone call, which was followed by a mailed survey packet if no contact was made.
All follow-up data were obtained no more than 1 week before or after each scheduled 3-month follow-up time point. When evaluating patient-reported function and pain, studies have shown that clinical services and the majority of change occurs within the 3-month postoperative period [ 2426 ].
Comorbidities have been shown to influence functional outcomes of following TKA. To account for these factors, baseline clinical information was collected via retrospective chart review of the electronic medical record.
These data included a documented history or clinical diagnosis of depression, anxiety, and back pain with specific category for low back pain.
Classification for a history or clinical diagnosis of diabetes for this study did not include gestational diabetes, glycemic disorders e.
Finally, patients were considered to have a history of cardiovascular disease if there was documentation of a history or clinical diagnosis of coronary artery disease, myocardial infarction, stroke, arrhythmia, valvular disease, or heart failure [ 24 ].
revisionprevious TKA on the contralateral side, diagnostic criteria knee arthritis etiologysmoking status, and pack years were also collected in the retrospective chart review. Pain catastrophizing scores were calculated using the Pain Catastrophizing Scale PCS [ 526 ].
This scale is useful because it analyzes recent pain-related thoughts. The PCS score is obtained by summing the values for all 13 items within the measure. Scores range from 0 to 52 and higher scores indicate increased pain catastrophizing.
Patient resilience scores were calculated using the Brief Resilience Scale BRS [ 11 ]. This scale represents the concept of resilience most directly, whereas other scales are more reflective of the personality traits and strategies that patients utilize in order to increase their resilience.
Items on the BRS are scored on a 5-point Likert Scale. The total BRS score range 1—5 is an average of all of the items after reverse coding 3 items with higher scores indicating more resilient individuals. The following standardized instruments were utilized to collect patient-reported information regarding health:.
The KOOS, JR. The KOOS Jr. questions capture patient opinions up to 1 week prior to survey administration. Scores are transformed to a scale ranging from 0 towith higher scores representing better knee function. The test has been validated against legacy measures, the Western Ontario and McMaster Universities Osteoarthritis Index WOMAC and full-length KOOS, which take considerably longer to administer [ 27 ].
This measure is also recommended for use with patients undergoing TKA in the perioperative period by the Centers for Medicare and Medicaid under the Comprehensive Care for Joint Replacement Model [ 28 ]. This instrument utilizes 10 items to provide an assessment of different components of patient quality-of-life.
T-score tables are used for comparison of the physical and mental health raw scores to the general population [ 31 ]. After conversion, 50 is the mean, and converted t-scores that are 10 points below or above this number are understood to be 1 standard deviation away from the mean [ 30 ].
This allows for comparison of the mental and physical health scores to the general population with higher scores indicating better health. A sample size of patients, achieves at least The variable tested can be adjusted for up to an additional 15 independent variable s.
An effect size of 0. Cohen's f 2 interpretation: 0. Thus, we were adequately powered to detect a small to medium effect size.
Additional patients were recruited assuming that some patients would be lost to follow-up [ 32 ]. Continuous variables are presented using the mean and standard deviation SD or median with 25th and 75th percentiles dependent on data distribution. Normality of continuous data was assessed using the Shapiro—Wilk test.
Categorical variables are described using counts and percentages of non-missing data. Certain categorical variables were simplified into common subgroups to reduce categories and increase power.
Correlations among continuous preoperative variables were determined by calculating Pearson correlation coefficients to determine the linear relationship. Multivariable linear regression models were constructed for each 3-month postoperative primary outcome, including KOOS and PROMIS GH and MH.
The goal was to describe the independent association between each of resilience and pain catastrophizing and the outcome variable of interest. Based on our predetermined data collection procedures we anticipated the number of missing patients would be low.
Therefore, we constructed three multivariable models for knee function, general physical health, and general mental health using only complete cases. Preoperative covariates were chosen for each of three models using univariable linear regression analyses to determine the relationship of each preoperative variable described in Table 1 to each outcome.
Therefore, covariates for each model vary.
: Joint health resilience| Everything at a Glance | Schellenberg, E. Capability: Management of population-based payment models. Brower joined Trinity Health from Atrius Health in Massachusetts, where she last served as vice president of Population Health. that might pose a conflict of interest in connection with the submitted article. Measurement Track: Payment Reform Capability: Leveraging multiple reports integrated clinical, claims, quality, and financial data Definition: Reporting includes information captured from electronic health records, claims-based records, quality analysis, and financial sources. Artrite reumatoide e qualidade do sono. In this activity, they are completely free to express their ideas on creating this character through moving, creating sound, writing and drawing. |
| Healthcare Resiliency Framework - Health Care Payment Learning & Action Network | Moreover, the fact that the education systems are found unprepared to cope with the unprecedented numbers of refugee children, leads to abundant challenges in the education systems Kostoulas-Makrakis and Makrakis, Music, Informal Learning and the School: A New Classroom Pedagogy. Her role includes creating primary care payment reforms in New Mexico Medicaid that move toward paying for quality and population health. Cambridge, MA: Harvard University Press. Music practice and participation for psychological well-being: a review of how music influences positive emotion, engagement, relationships, meaning, and accomplishment. |
| Building Resilience | Definition: Gaining experience in Treatment options available payment models Joing payments Elderberry gummies for kids reporting Treatment options available hhealth penalties for not resiliennce data. Article CAS PubMed PubMed Central Google Scholar Joint health resilience RR, Haythornthwaite JA, Smith Healht, Klick B, Katz JN. Definition: Collaborate across primary and specialty care on coordinated patient-centered care delivery. Definition: Ability of multiple types of users across the organization to access clinical data to develop corresponding analytics for care management and reporting. Article PubMed Google Scholar Schreurs BW, Hannink G. Definition: Application of blinded quality performance results comparisons between individual providers to drive provider-specific process improvements. For optimal benefits, continue usage for an extended period. |
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We built Resilience inside Praxis — our custom training software — for flexibility and convenience: 34 training sessions you can repeat as often as you like. All your scheduling, timekeeping, and tracking are built in. Detailed instruction and exercise tutorials you can review anytime. Resilience will make you tough- er , but we can only do so much… Please still be responsible for your own safety and take good care of yourself. You deserve it, and so do the people who count on you 🙂. How much space do I need? |
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