iii Book: 'Complexity in Health Care - A Paradigm Shift for Clinical Practice'

In reading this book and others on W2tQ, I must make the following points:

  * my need to remember the purely USA context (I have never worked there);
  * my healthcare, nursing, informatics experience is NHS-based;
  * this review (and others) is motivated by the project here - Hodges' model;
  * as a result, I will be quoting heavily, there is much to bring to your attention.

As noted in post (i) there is much to whet the appetite, a paradigm shift, 'comprehensive, collaborative, and integrated care' (p.11) certainly have become popular topics in the medical literature. Not only that but 'interpersonal and intersubjective treatment models' too (p.12).

The role of 'Case Managers' is highlighted, plus the Case Management Society of America, which is committed to:

•  Improved Consumer Health Outcomes
•  Professional Diversity, Equity, and Inclusion
•  Cultural Competency and Humility
•  Advocacy for the Health Consumer
•  Integrity and Ethical Principles
•  Promoting Health Equity
•  Educating Case Managers Across the Care Continuum
•  Evidence-based Quality Care
•  Holistic, Compassionate Care
•  Fostering Communication and Collaboration
•  Advancing Research, Innovation, and Use of Technology
•  Fiscal Accountability [ https://cmsa.org/about/ ]

Whether the USA influences global trends in the structure and form of healthcare is another post, but there is a UK Case Management Society too: https://www.cmsuk.org. I can see a fit here [UK] with the development in recent decades on social prescribing. A different role, of course but part of a complex jig-saw.

As expected definitions are provided: 

'Roger Kathol has eloquently defined "health complexity" as "the interference with the achievement of expected or desired health and cost outcomes, due to the interaction of biological, psychological, social and health systems factors when patients are exposed to standard care delivered by their doctors" [1].' p.10. 

Roger G. Kathol, Rachel L. Andrew, Michelle Squire, Peter J. Dehnel (2018) The Integrated Case Management Manual: Value-Based Assistance to Complex Medical and Behavioral Health Patients. 2nd ed. Basel: Springer.

I can see where this definition comes from, but for me, it does not sit right. The problem when there is 'interference' is the assignment of responsibility and consequence that blame can follow. We've seen this, and in mental health too), with the recover model^. Some of the terms here may be completely innocuous politically speaking (which is the author's intent of course), but they can also be 'weighted'. Hence they can become concrete terms of judgement. Think about it: achievement, expected, desired, cost (and) outcomes, standard care, delivered (by doctors)? Or, am I over-thinking again.

In the margin I pencilled/drew:

individual

|

INTERPERSONAL : SCIENCES

humanistic ------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

Standard -	care
Other -	factors

As ever, the individual patient is our focus. The individual is supported (literally) by the social and political (infra-)structures that act as a scaffold, safety-net for most.

Time flies, I can't believe it was 2007 I posted 

Plush HQ foyer, shame about the mannequins!

I had this notion of life-size cardboard cutouts representing the average people who use a given health service provider (local, or not so local these days?). The data will be there in statistical annual reports. I'd noticed the displays - analogue and digital that greeted visitors at a local NHS Trust HQ. This would be the book's 'routine patients' who receive standard care. 

Chapter 3 introduces 'variables' which again is brief, but imporant as variables recur throughout the book. The 'Clinical Field' is first outlined, as in:

• Sources of clinically relevant factors;
• Dynamic factors;
• and: Variables representing contributions from practitioner(s).

Abstract variables are differentiated from those that are concrete. It's reassuring to read there is no true simplicity within the clinical field, and the author's goal is to 'unpack complexity so it remains as true to life as possible, not just manageable conceptually.' p.18.

Frankel et al. are primed to go beyond this. Maths, as in statistical procedures are one tool. Chapter 4 adds to this with a theoretical model to guide clinical understanding of patients with biopsychosocial complexities, the foundations of our paradigm shift. p.23.

If you have an understanding of Hodges' model you can picture my response to this. But, staying grounded, the whole book and paradigm shift represents a form of scientific "emergence". It is frustrating that literature searches fail to pick out Hodges' model. 

Frustrating too as reading of "awe", also on page 23, I have experienced this many times (over say 1977 - 2019 ...). So, I held on to my dummy (pacifier!?) and read on ...  

Chapter 4 Technical Considerations is one the longest and contributes all of Part III. Here you can read about science, measurement, statistics, empirical, operational definitions, intelligence, reliability. I often see a chapter, book section as a useful primer for students and the same applies here; with inter-judge realiability, validity, control, null hypothesis, statistical methods and much more. Reference to mathematics (axiomatic too) had me hoping for more. I picked out Structural Equation Modelling:

 'We would also like to suggest that following the steps involved in "structural equation modeling" (path analysis) is a good way of conceptualizing and reasoning about complex clinical variables altogether. For example, constructing a clinical model informally (intuitively, loosely from data) and thinking about (diagramming) how the variables involved may moderate and mediate each other can be a useful activity for clarifying the nature and requirements of a complicated clinica1 situation. 
 

 In simplest terms, an independent variable is the causal or influential variable that impacts and effects the dependent variable. A moderating variable is a dichotomy, and refers to two comparison groups (e.g., male/female; passed/fail; religious/nonreligious; tall/short; high versus low socioeconomic status) that display significantly different degrees of magnitude on a correlated relationship. For example, the relationship between a specific treatment for a medical disorder and treatment outcomes may be moderated by socioeconomic differences. The treatment outcome relationship may be stronger and more positive for individuals with elevated socioeconomic standing who therefore have better support systems and access to medical professionals, and fewer economic stressors.' p.36.

I think from this the authors might be sympathetic to giving 'life' to the POLITICAL domain and Hodges' model; after all it lives in people's daily experience - acknowledged or not. The book's structure works thus far: Chapter 5 Nature-Nurture (n.b. no escape!)  and the Epigenome. The structure - flow - works, as at just over four pages, it begs further reading (beyond the listed references). I still have my copy of:

Fritjof Capra and Pier Luigi Luisi (2014) The Systems View of Life - A Unifying Vision. Cambridge: Cambridge University Press.

 

With the epigenome being added to the 'patient complexity equation' in chapter 5, I wondered whether this was predictable, a promise, or a tease?

individual

|

INTERPERSONAL : SCIENCES

humanistic ------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

nature?	NATURE?
NURTURE?	nurture?

 

Previously: 'complex' : 'nature' : 'mental health' : 'person(-centred)'

More to follow ...

^Jones P. (2014) Using a conceptual framework to explore the dimensions of recovery and their relationship to service user choice and self-determination. International Journal of Person Centered Medicine. Vol 3, No 4, (2013) pp.305-311. 

Steven A. Frankel, Steven D. Thurber, James A. Bourgeois (2023) Complexity in Health Care: A Paradigm Shift for Clinical Practice. Cham. Switzerland: Springer. ISBN: 978303114948.

Help for NHS.jobs and job hunters with standard file names

NHS.jobs is a marvellous web resource. Once you have entered your personal and career details you can save time and focus on what matters....

One thing I've noticed is that should you download assorted 'job descriptions', 'person specifications' and other essential guidance the files become meaningless when listed.

Browsers and operating systems do behave differently, but on my PC extra characters are appended to differentiate one 'jobdescription.doc (or pdf)' file from another.

There must be a way to define a standard across the NHS (and dare we suggest the social care sector)? Then prospective job-hunters can see from the file name the organisation, the job title, closing date or other combination of details? Given the redundancy in our language(s), the need for equality (in access) it would not take much to achieve this?

There are some points of note: what's the shelf (directory!) life of these files? "If you have not heard from us within four weeks of the closing date then please assume your application has been unsuccessful on this occasion."... Plus, the semantic web and an intelligent file system may overtake this problem and perceived requirement, but until then...?

Even if only gifted a recommended convention, then perhaps this could quickly emerge as a standard, because it makes a difference, affords an early advantage in the 'market place' and assists everyone.


As the demographic squeeze tightens its grip this might even help HR departments, students, returnees, and the middle-aged-mid-career-crises-smitten.

Until then NHS.jobs and job hunters can only handle the files they 'receive'.

NHS.jobs does very well in helping to open doors... in the meantime I'll keep knocking ... and anyway what date did I save that person spec?



Image source - previously at: http://www.ectomo.com

'Thinking outside the box: alternatives to standard inpatient mental health care' by Amber Jarvis

c/o The Mental Elf on 'X' I came across a blog post by Amber Jarvis:

Thinking outside the box: alternatives to standard inpatient mental health care

Amber's post considers a study by:

Griffiths, J. L., Baldwin, H., Vasikaran, J., Jarvis, R., Pillutla, R., Saunders, K. R., … & Johnson, S. (2025). Alternative approaches to standard inpatient mental health care: development of a typology of service models. International Journal of Mental Health Systems, 19(1), 1-13: https://pubmed.ncbi.nlm.nih.gov/40247283/

At an online meeting this evening, near the close the discussion loosened and alighted on AI. The ability of AI to summarise a large text file, a *.pdf and create discrete web HTML pages. The racial bias 'built-in' by human coders, reflected in outputs; that point to structural racism. 

Finding this paper on X, boxes are the bread and butter of Hodges' model. Not just thinking outside a box, or inside one, but several and with a final twist - to follow. Amber begins:

'Inpatient mental health care involves staying in a hospital or specialised facility to receive intensive, round-the-clock support for serious mental health needs (Staniszewska et al., 2019). Whereas acute inpatient services typically respond to immediate crises, longer-term wards support individuals with more complex needs and a higher level of ongoing risk.

Inpatient services are a core component of our mental health system — whether someone stays for a night, weeks, or even several years. However, inpatient care has recently come under growing scrutiny – and for good reason.'

A Community Mental Health Nurse since 1985, my in-patient experience is a tad misty, but not misty-eyed. As the wards: psychogeriatrics, long-stay, female acute admission were simultaneously challenging, rewarding - in the sense of being able to make a positive difference, changing what were institutionalised practices, no personal clothes, lockers, tea urn, no banking, few visitors (admission wards excepted). It was all very quotidian: check the bath book. Then tell, confirm, assure the patient, 'yes!'. It is your bath day. I've posted previously about critical mental health. You do (should?) quickly learn you are part of a system, a machine; and the distinction between person- patient-centred and service-centred care. The need to do my 'general' quickly emerged too. 

As ever, two words, across Amber's post and Griffith et al's title, stand out; 'map' and 'typology'. I must revisit and post about:

Macduff C. (2007). Typologies in nursing: a review of the literature. Nurse researcher, 14(2), 40–50. https://doi.org/10.7748/nr2007.01.14.2.40.c6020

Part-time work since 2020, in two adult CMHTs and a recovery team, has provided an update. The first as COVID emerged, was a bit of a shock in terms of diagnoses, caseness, the proximity to the law and forensic psychiatry, thresholds for referral, changes to mental health law (that were now more practical) and the management of patient's finances. 

So, to return to last night's brief online discussion, the observation of how racism is ongoing, brought up the fact of racism being structural and institutional (Dean & Thorpe, 2022). The change needed is an intergenerational break, which doesn't bear thinking about. The National HEALTH Service faces the same challenges in the shift to prevention, and addressing racism. Where is the workforce, going to come from, to help recovery, health and related literacies (media, emotional, financial)?

It is easy in boxes like Hodges' model (and others) to be idealistic. Ideally as I learned of Community Psychiatric Nurses being recruited, six of us, we all should have asked:

What is the plan?

What is the model of care?

What characterises 'care in the community'?

How do we prevent relapse, readmission?

Is there a 'halfway house'*?

We did, to an extent. There was great enthusiasm, motivation, idealism, co-ordination, collaboration  (Tyrer & Gelder, 1990) and leadership. 'We' had an association,^ and a journal. Back then the Royal College of Psychiatry produced a report on CPNs. Is there a message in this? Progress was and has been made, but the promise has not been delivered. With care in the community having regressed, an incomplete 'project'.

I will read more and revise this post, or more likely add another: with less 'history' ...

Individual

|

      INTERPERSONAL    :     SCIENCES               

HUMANISTIC  --------------------------------------  MECHANISTIC      

 SOCIOLOGY  :    POLITICAL 

|

Group

Model of Care	Model of care
Model of Care Care in Community Children - Schools - Education	Model of care 'Care Leavers'

*'Cross-settings' in Griffith et al.

^https://www.unitetheunion.org/what-we-do/unite-in-your-sector/health-sector/mental-health-nurses-association

Lorraine T Dean, Roland J Thorpe, What Structural Racism Is (or Is Not) and How to Measure It: Clarity for Public Health and Medical Researchers, American Journal of Epidemiology, Volume 191, Issue 9, September 2022, Pages 1521–1526, https://doi.org/10.1093/aje/kwac112

Tyrer P, Gelder M. The future of community psychiatric nursing: some research findings. Psychiatric Bulletin. 1990;14(9):550-551. doi:10.1192/pb.14.9.550

ii 'Thinking outside the box ...'

iii 'Thinking outside the box ...'

See also: 'institution' : 'racism' : 'typology' : 'map' : 'Forensic'

ii 'Thinking outside the box ...' by Amber Javis

Second reply to a blog post by Amber Jarvis on The Mental Elf:

Thinking outside the box: alternatives to standard inpatient mental health care

Amber's post considers a study by:

Griffiths, J. L., Baldwin, H., Vasikaran, J., Jarvis, R., Pillutla, R., Saunders, K. R., … & Johnson, S. (2025). Alternative approaches to standard inpatient mental health care: development of a typology of service models. International Journal of Mental Health Systems, 19(1), 1-13: https://pubmed.ncbi.nlm.nih.gov/40247283/

Jarvis highlights concern within inpatient services of:

'use of coercive practices ... (Nyttingnes et al., 2018; Belayneh et al., 2024). These include physical restraint (physically holding a person), seclusion (holding a person in a locked room) and chemical restraint (the use of sedating medication to manage distress or behaviour, sometimes administered “as needed” rather than as part of any planned treatment). Poor relationships between staff and service users have also been noted, ...'

Reflecting since the previous post, I realise that I encountered efforts to prevent admission and treat in the community prior to going part-time. A short stay unit at a general hospital. Being a member of Intermediate Support for older adults; shifts ran 0800-2000 - early or late. Then working part-time, there were short-stay placements in the community that the recovery team would visit providing support.

Mental distress is distressing (a truism of course), both as lived experience (with or without self-awareness in-situ/crisis) and for others in the vicinity. Family, friends - who see a person they thought they knew, perhaps even thought they were a friend, a person who loved them; but now!? They present as distant, aggressive, subdued, agitated, unpredictable, inconsolable and possibly expressing thoughts of self-harm, threats to harm others, or totally bizarre, 'psychotic' ideas. This is not the person they thought they knew. For the person affected, familiars are strangers. A relational breakdown. We forget the severely mentally ill at our peril. A pervasive sense of helplessness is readily transferred: the reflex conclusion that help is needed - and fast.

To say we are creatures of habit, is to also acknowledge that change our environment results in a change in our behaviour. When relatives did arrive on the psychogeriatric ward I mentioned previously, they cried. Apologising for the environment, yes; efforts to reassure ensued and eventually family, friends were won over. They shouldn't have been. Unless we're in a game, play, or movie, who wants to find themselves in a Victorian era institution?

I've posted previously (or is it in draft?) on the importance of design in the design of care environments. It was a relative's visit to a care home, that resulted in a nursing home design business (Sunday Times). 

A person who is severely mentally ill needs service-centred care, not purely person-centred care. Person-centredness is key, but safety of self, and the public soon makes itself known. We also forget this at our peril. The problem is that control, and law literally take over. Plus, it's our place not yours. Loss of power the person struggling, ill, in crisis then follows. Amber continues:

'The concerns described above chime uncomfortably with modern mental health agendas of prioritising autonomy, compassion, trauma-informed and person-centred care. In light of these tensions, and the growing number of crisis alternatives – ranging from crisis cafes to intensive home treatment services – researchers  at the NIHR Policy Research Unit in Mental Health set out to map current alternatives to traditional inpatient care, both nationally and internationally. Griffiths and Baldwin’s findings raise important questions about how mental health services could evolve to better suit people’s needs, providing a valuable starting point for service planners considering developments in care.'

Hodges' model is ideal to help reflect and critique the relation-ship between 'a person' and 'the service'. I passed two gentlemen in London over the weekend. Clearly unkempt, standing but gesticulating, freely verbalising, incoherent on passing. Neither appeared intoxicated ( but I wasn't that close) or 'stoned'. That's the other question; passing-by what was I going to do? Does the 'community' care? On 'X' you encounter the extremes of debate. Anti-psychiatry, resort to and risks of dependence on medication - anti-depressants, anxiolytics; the damage from anti-psychotic drugs and atypical antipsychotics. The continuous debate about ECT. A dizzying stream of texts about mental health, over-diagnosis and wellbeing:

Medical prescribing has a partner. Social prescribing is well established, with organisations, events, publications and research emerging. People, have scoffed at the suggestion that gardening can help; or going for a run. Especially when you can't get out of bed. Chronic fatigue syndrome, long-COVID are seemingly monolithic in their resistance to change. A real challenge and so counter to the person's 'pre-morbid' personality and lifestyle.

For several years the state of mental health nursing as a specialty has been questioned. Is the mental health nursing curriculum being genericised? Enrollment of students nurses in learning disability has also dropped.

RCN questions separation of mental health nurse training (28 March 2025)

Medical prescribing has a partner. Social prescribing is well established, with organisations, events, publications and research emerging. People, have scoffed at the suggestion that gardening can help; or going for a run. Especially when they can't get out of bed. Chronic fatigue syndrome, long-COVID are seemingly monolithic in their resistance to change. A real challenge and so counter to the person's 'pre-morbid' personality and lifestyle. As a conceptual framework Hodges' model is ideal as a semantic net, to reflect and critique concepts that stretch and so disrupt (for a time) out norms. Concepts with a dual character. If social prescribing is one example, take crisis cafe mentioned by Jarvis above. If you think in physical - environmental terms where do you envisage a crisis occuring or playing out? What about a cafe? What is the ambience of these places?

I noticed a little visual game, an animation of characters running, jumping, climbing over an obstacle course. You focus on one figure and follow them for a time. This makes a difference, called distraction. In psychosocial intervention and managment of psychosis and anxiety audio - music, poetry, repetition has also bee used. The essence here must be when the intervention begins. Recognising relapse triggers, requires preparatory work. The Griffith reference is provided, but Jarvis begins to describe the results:

'Researchers identified 65 alternative service models to standard inpatient care. These were organised broadly organised according to the setting (e.g., community-based, hospital-based, or cross-setting) and the target population (e.g., adults versus children). Across these categories, ‘community-based alternatives’ were the most common category of alternative service models, followed by hospital-based and cross-setting approaches. We’ll explore each of these in more detail below.'

In post (i) and here I suppose I am advocating for mental health nursing as a distinct programme of study, practice and proven competence. For several years the state of mental health nursing as a specialty has been questioned. Is the mental health nursing curriculum being genericised? Enrollment of students nurses in learning disability has also dropped. 

RCN questions separation of mental health nurse training (28 March 2025)

There is a saying: 'You get what you pay for'. There is a sense that there are people who would like to ignore, deny, erase 'mental health'. After all, the truth really is that you can 'see' a broken leg. This isn't an issue if you can afford a private psychotherapist, or a psychoanalyst.

The elephant here (well, there always is one) is education and the literacies. For prevention: the ultimate change - this is where we must focus. But of course for the problem at hand - and mind it is too late.

(Post iii likely to follow.)

Individual

|

      INTERPERSONAL    :     SCIENCES               

HUMANISTIC  --------------------------------------  MECHANISTIC      

 SOCIOLOGY  :    POLITICAL 

|

Group

subjectivity          mental state - crisis - mind quality	objectivity hand - physical state - crisis quantity
Social prescribing Cafe	Housing - crisis Cost of living - crisis

See also: 'literacy' : 'prevention' : 'service' : 'severe' : 'change'

'Thinking outside the box ...' i

iii 'Thinking outside the box ...'

'Sophisticated cultural relativism: Bernard Williams' c/o Bond (1996)

INDIVIDUAL

|

     INTERPERSONAL    :     SCIENCES               

HUMANISTIC --------------------------------------  MECHANISTIC      

SOCIOLOGY  :   POLITICAL 

|

GROUP

"Transcendental standpoint The perspective of the person who evaluates or questions or reflects upon a moral issue by consciously examining the issue from an objective perspective Uses "thin" concepts such as "good" or "ought" in the process  Take the question "Is it really true that I ought not to tell lies?" In order to answer this question some moral authority or standard must be referred to. No answer can be found because there is no universal moral standard to appeal to. SUBJECTIVE

OBJECTIVE

A culture Moral truths exist                These are: 1. Non-objectivist truths (belong to and are valid within this particular culture) 2. Non-reflective (use the "thick" concepts of the culture, e.g. "liar", "bully." These carry within them their moral meaning. For this reason, no conscious reflection is needed in identifying a truth)" p.28.

"The evaluative perspective The perspective of the person living in the culture who is stating and thinking about moral truths."

Based on Figure 2.1 Sophisticated cultural relativism: Bernard Williams. In
Bond, E.J. (1996). Ethics and Human Well-Being: An Introduction to Moral Philosophy. Cambridge, Mass.: Wiley-Blackwell. p.28.

AI, Nursing, Safety and presentation - 1st Aug 2-3pm

Hodges' model was not created primarily as a safety tool. It cannot claim to achieve or adhere to an ISO standard. ISO 45001 - health and safety management standard, for example. There is however a relation to clinical risk across healthcare professions, disciplines and clinical fields, including community and public (mental) health. To which of course we must now add planetary health. That said, the question of ISO safety and quality standards for Hodges' model has not been assessed. What exactly would certification entail? Would this process be appropriate for what is a generic - foundational tool?

What this means, however, is that as a situated model for reflection, reflective practice and critical thinking Hodges' model constitutes a deliberative step in the right (formal) direction. As noted previously, in template form, Hodges' model acknowledges the initial personal, professional and organisational standards that (must) shape our clinical encounters. That is, if assessed (as students - and our peers clearly are, and you would expect to be), unconditional positive regard would be observed, supported by the required standards of professional behaviour. 

There is another step here. The ethical and legal edict of 'do no harm' must also be central to care delivery, outcomes and evaluation. So from the outset, implicit in Hodges' model is the (NON-LEGAL) statement:

You, the practitioner - agent (student - and your mentor/supervisor) will not knowingly, or through professional ignorance, or neglect  cause physical, psychological, social (cultural), political (power), or spiritual harm to the patient - subject (or their carer - guardian/proxy).

There is no escape from AI and Large Language Models as I noticed in FTWeekend:

'Jilin University Hospital in the eastern city of Changchun has rolled out a diagnostic tool it claims can produce treatment plans through DeepSeek consulting the hospital's database, medical guidelines and drug efficacy results. Jinxin Women and Children's Hospital in south-western China said it had a tool for patients to track their ovulation cycles, with test results combined with the hospital's patient data to produce personalised fertility plans.

One doctor at public hospital in Hubei province in central China said the institution's leadership had issued a directive that DeepSeek should be used as a third-party arbiter if two doctors have differing views on treatment.

 
There have been rollouts in public hospitals in Chengdu, Hangzhou and Wuhan for less complex applications, such as digital nurses directing patients to the right consulting room or explaining complicated medical reports.

 
Several industry insiders warned against taking all the announcements at face value, as some companies were trying to capture investor enthusiasm around DeepSeek without meaningfully deploying its models. Meanwhile, government bodies are also under political pressure to be seen as aligned with China's AI darling.

 
The SOE tech supplier said "much work still needs to be done to make these models useful" for more complex work such as medical diagnosis. "It must be trained on enough medical data to produce good results. This will take time and needs collaboration from leading AI companies. It is not something hospitals can buld on their own."

Another doctor described a move to deploy DeepSeek last week at a hospital in eastern Zhejiang as a "publicity stunt".

Even if some announcements should be treated with scepticism, experts say the willingness to test out its models still marks a step change.'

Edited for formatting, some text is emphasised. A vast array of conditions can be substituted (parametrised) for 'fertility'. While nursing is mentioned there is little on testing, but for 'plans' we can read nursing assessment, plans, and evaluations. 

Returning to safety. Following an online chat yesterday, I've an online presentation to the Patient Safety Management Network [Patient Safety Hub] pencilled in for 1st August 2-3pm. Comprised of 40 minutes with questions following - I will, as discussed - focus upon:

• Introduction to the model
• How it can be applied in different situations – safety/risk/improvement
• Examples of its use

This is progress - a step to develop Hodges' model and reveal the limits of the bio-psycho-social model.

^soe - state-owned enterprises.

Olcott, E., Ding, W. AI challenger DeepSeek spreads rapidly across China with the blessing of Beijing, FTWeekend, 1-2 March, 2025. p.13.

Records 2: Flying the standard

'Records I' was posted last September, time to revisit this theme...

If I am a real champion of Hodges' model, convinced of the value and care-worthiness of this 21st century conceptual framework then why have I not been an agent of change@work?

Surely, I would not have stopped short of stepping on toes, or letting a lack of evidence get in the way of advocating the model as a solution to real problems? So why haven't I been the standard bearer where it really matters - on the shop floor? Excuses are many and include:

• the personal - part-time nature of my combined nursing-informatics interest;
• following local policy Care Programme Approach [CPA];
• professional accountability - risk assessment and management and working as a CPA lead;
• watching with interest as the Single Assessment Process joined the fray;
• and even more recently the Common Assessment Framework;
• plus, and this may be a cop out - I like people to decide/discover things for themselves.

Having been away from the clinical practice from Nov 2004 to last summer I was informed as to how much things had changed. After a short period of time I realised on the contrary how little things had changed.

We are still completing paper documentation designed for risk assessment, service engagement and case management of younger adults. Sometimes this focus and attention is justified with older adults, but this is rarely the case. Case files end up with pages of redundant white-space, white noise that slows what we might call conventional information retrieval.

It has been recognised for a long time that IT systems are key to unlocking multidisciplinary working and joining the dots of policy across health, social care and associated care sectors. The outcome of the CPA review is due later this month, it will be very interesting to see the direction this takes and what hooks there are for Hodges' model. The hooks I can see and well and truly intend to snag my lip upon here include:

• "paperless working";
• self-assessment;
• e-working at the point of care;
• collaborative working and treatment with education interventions;
• individual budgets and new commissioning models;
• social inclusion, social enterprise;
• social capital and employment.

Ultimately, I do believe Hodges' model will find its niche - why? Clearly, the 4P's with records and policy in particular are becoming ever more complex. At times like this a tool to -

simplify and summarise : engage and educate

- must have a place in our curricula, paper and e-record systems, client's and carer's hands and our cognitive tool sets.

Ack: links Care Services Improvement Partnership.

NHS Corridor Care – Urgent and Emergency Care Daily Situation Reports

If politicians & policymakers regularly 'walked'
 all the corridors of Hodges' model -
 they would see the false economy 
of their combined incremental works.

Incremental? Yes, in first being a 'temporary measure', then having a deleterious impact as the duration per patient and number of patients on corridors increased.

Now to the situation when the standard of care is unsafe, sub-standard, and denigrates the NHS as a social institution.

The fact of insufficient beds and its effect on care (pathways) and patient (and family) experiences severely affects staff morale, as they recognise subtle abuse, a precursor to structural and attitudinal changes that foster, encourage and establish institutionalised harm.

Staff also realise that they risk being de-skilled, 're-educated' -
becoming less compassionate ... (a 'lesser Nurse') as corridor care 
and its consequences are normalised.

Ignoring demographic trends and without an alternative concerted 
preventive/health education and health promoting plan, this is the result 
of the health and social care funding and policy
of successive governments, enacted by NHS management.

NHS England: Corridor Care – Urgent and Emergency Care Daily Situation Reports
https://www.england.nhs.uk/statistics/statistical-work-areas/corridor-care-urgent-and-emergency-care-daily-situation-reports/

Call For Papers: Special Track on AI for Tackling Dis/Misinformation during Pandemics

Call For Papers: Special Track on AI for Tackling Dis/Misinformation during Pandemics In conjunction with the ACM International Conference on Information Technology for Social Good (GoodIT 2021)

The GoodIT conference is sponsored by ACM SIGCAS, the Association for
Computing Machinery's Special Interest Group on Computers & Society.

The conference focuses on the application of IT technologies to social good.

The Special Track on AI for Tackling Dis/Misinformation during Pandemics focuses on new data technologies based on artificial intelligence, data governance, machine learning, natural language
processing, and social network analysis to aid experts in analyzing large volumes of social media data in order to detect fake news, misinformation, and disinformation. A number of open challenges need
more investigation from the research community, such as recent trends in composing information disorder by combining false and real content, the mechanisms that drive fake content diffusion during pandemics, how to differentiate fake content from personal viewpoints, why people tend to believe fake content and make decisions based on it during pandemics, and what are the different motivations behind the dissemination of fake content. Fact-checking and claim verification are two important strategies that are worth incorporating in the automated tackling and curtailment of fake content during and after pandemics.

************ Key Dates ************

Papers Submission Due:      May 1, 2021

Authors Notifications:        June 22, 2021

Final Manuscript Due:        July 10, 2021

GoodIT 2021:                    September 09-11, 2021

************ Important Links ************

Special Track Website: https://aitdmp.conceptechint.net

Submission Link: https://goodit2021.hotcrp.com/

************ Submission Guidelines  ************

All submissions will be reviewed using a single-blind review process.

The identity of referees will not be revealed to authors, but authors can keep their names on the submitted papers, on figures, bibliography, etc.

Papers should not exceed 6 pages (US letter size) double column including figures, tables, and references in standard ACM format. Papers must be submitted electronically in printable PDF form.

Templates for the standard ACM format can be found here:

https://www.acm.org/publications/proceedings-template No changes to margins, spacing, or font sizes are allowed from those specified by the style files. Papers violating the formatting guidelines will be

returned without review.

ACM has partnered with Overleaf, a free cloud-based, collaborative authoring tool, to provide an ACM LaTeX authoring template. The ACM LaTeX template on Overleaf platform is available to all ACM authors at: www.overleaf.com/gallery/tagged/acm-official

Accepted papers will be included in the ACM Digital Library. 

Special  issues associated with the conference are being organized.

************ Topics ************

Papers on practical as well as on theoretical topics and problems in various topics related to rumors, fake news, misinformation, and disinformation during and after pandemics, are invited, with special emphasis on novel techniques and tools for automated tackling and curtailment of fake content during and after pandemics. Topics include(but are not limited to):

• AI approaches for the detection of online influence and manipulation
• AI approaches to identify misinformation and disinformation campaigns
• AI approaches for spotting misinformation and disinformation spreaders.
• Social media mining for automated detection of misinformation propagation and disinformation circulation
• AI approaches for automated identification and verification of claims
• AI approaches for intention detection for misinformation and disinformation contents
• AI approaches for credibility assessment of Social media sources
• AI approaches for fake news curtailment, filtering and prevention.
• AI approaches for analysis/detection of distributed and multi-platform misinformation and disinformation disseminations
• AI approaches for predicting the Impact of misinformation and disinformation during pandemics
• New datasets and evaluation methodologies to aid in automated detection and analysis of misinformation and disinformation content in social media channels

**********The Conference Sponsored by**********

Association for Computing Machinery's Special Interest Group on Computers & Society http://www.sigcas.org/

This workshop is supported by the Association of Cyber Forensics and Threat Investigators (www.acfti.org) and the Industrial Cybersecurity Center (www.cci-es.org).

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This message was issued to members of www.jiscmail.ac.uk/SOCIOTECH, a mailing list hosted by www.jiscmail.ac.uk

Thanks to Andrew Zayine.

Two policy initiatives related to Digital and eHealth - RCN

Dear eHealth forum members 

[c/o RCN]

We just wanted to alert you to two policy initiatives related to Digital and eHealth.

1. The Digital Nursing programme in England is seeking feedback on their consultation on having a Standard for Nursing Documentation. The draft standard and form to give feedback [by 21st July] are available on the NHS futures website (https://future.nhs.uk/DigitalNursesNetwork/view?objectID=36339504). 

You may need to register to access the site:

image: FutureNHS - Digital Nursing Programme

2. NHS England has just released their plan for Digital health and social care (https://www.gov.uk/government/publications/a-plan-for-digital-health-and-social-care/a-plan-for-digital-health-and-social-care).

With very best wishes

The eHealth forum committee

n.b. Closing date for feedback added in text.

 

Sahana OSS response in Haiti

My source: Community informatics list [ciresearchers]:
Sahana Software Foundation
Haiti Earthquake Response
Status Report #1
January 17, 2010 00:00 UTC

The Sahana Software Foundation and the Sahana community responded with a massive voluntary effort immediately following the earthquake that has devastated the poor country of Haiti. Working around the clock, we have set up a hosted instance of Sahana (the first deployment of SahanaPy following a disaster!) on a public website that is already filling gaps in the information management requirements of the massive relief operation.

Major Accomplishments

We have a Haiti 2010 Sahana Disaster Response Portal - a live and active website up at http://haiti.sahanafoundation.org which contains a feeds from many of the relief agencies and links to Sahana modules that are actively being used to help coordinate the relief effort.

We have a Sahana Haiti wiki page where we are tracking all of our and others' activites at: http://wiki.sahana.lk/doku.php/haiti:start

We have a requirements page where we record all the modification, configurations, and changes to Sahana based on the mission requirements at: http://wiki.sahana.lk/doku.php/haiti:requirements

See - https://sahanafoundation.org/products/eden/

The Haiti 2010 Sahana Disaster Response Portal provides the following functionality:

1. An Organization Registry - serves to track organizations and offices working on the ground in Haiti. Organizations are encouraged to self-register and report their office locations - alternatively, individual organization office or lists of offices can be e-mailed to haiti-orgs AT googlegroups.com and we have volunteers to assist with data entry and to aggregate lists from other sources. We have entered data from pre-disaster lists of organizations working in Haiti available from UN OCHA. We can assume that these organizations will be working on the relief efforts, but expect that most of their office locations will be different as most organizations have been forced to move into tents given that few buildings remain standing and usable in the capital. We are working to validate these lists with the organizations directly.

The site serves up both KML for Google Earth users and GeoRSS for everyone else, and will generate reports of organization activities and the gaps (uncovered sectors by geographic location). This site will hopefully become the main resource for accurate information about the organizations working on the ground, where they are located, and what activities they are engaged in, and the resources in terms of staff and equipment that they have available to them. (Currently, data is admittedly sparse but we expect more details to become available as the coordination efforts take root on the ground). We are coordinating with UN OCHA, Google and others on sources of accurate lists and updates.

What are the gaps in our information collection? We have a large and we think accurate list of organizations, but not much office location information. Without this, it becomes hard to generate data that can be used as a layer in a GIS system. We are encouraging people to report this information - preferably by GPS coordinates, but any location information that we can use to manually geo-reference the office is valuable. We hope to be able to enhance our capabilities such that we can produce polygons showing organization's areas of coverage by sector. Please direct organizations working in Haiti to our site to register their offices and activities!

2. A Missing Persons Registry / Disaster Victim Identification (DVI) Registry - we are working with Google and others on an agreed common standard for the exchange of Missings Persons data using the PFIF standard. The Google site at http://haiticrisis.appspot.com/ is the main aggregator collecting all missing and found persons reports and we are encouraging all people to send data to that site. [We are struggling a little as Google's feed is not fully PFIF compliant and the lack of unique record identifiers makes it more complex to set up true synchronization without the creation of duplicate records. We continue to work with Google on this and hope to have a resolution and solution within the next few hours.] We will also be embedding Google's widget on our site for collecting missing person information. Google will be making their data available via a PFIF feed and we will be importing it into Sahana's Missing Persons registry. From there, Sahana can add value to the simple lists being collected.

In particular, Sahana's Disaster Victims Identification registry - or DVI - which is used to management the handling and tracking and tracing of the deceased, dead bodies and their identification. There is currently no other known application for this and we hope that those working in this area will find Sahana extremely valuable. Sahana will have the ability to cross-reference missing persons information with the identified and unidentified deceased, thus facilitating reconciliation efforts. The Sahana Missing Persons registry has additional physical description information fields and we hope to be able to utilize some of the image matching capabilities available to extend these capabilities further. Organizations interested in utilizing these capabilities (which will not be made open for public use) should contact the Sahana team at
sahana-haiti AT lists.launchpad.net.

Any updated missing persons status information will be pushed back to the main Google repository from Sahana.

3. Situation Mapping - Sahana's site is able to map all of the geo-referenced data within Sahana - primarily the organization data, but we have also manually entered a data layer of hospitals and medical facilities. Sahana has worked with members of the OSGeo community to obtain a fast tiled set of the current imagery being made available by Digital Globe. Sahana is also leveraging the constantly updated set of Open Street Map tiles. These are acting as backdrop for the offices that are being entered as part of the Organization Registry. Other data sources that are ready and available to be leveraged by Sahana and SahanaPy for other deployments include reports from Ushahidi, various point layers from Open Street Map, location names, USGS earthquakes, and locations from GeoNames. We will continue to build out these capabilities further as relevant layers are made available.

Capabilities we are working on:

The following capabilities are in the process of being developed and we expect will soon be available:

4. Request Management: We are working with the US State Department, Ushahidi and some other voluntary efforts on a project to process SMS messages with requests for assistance sent from survivors in Haiti. SMS text messages sent to a short code in Haiti will go into Ushahidi, who will have volunteer translators to add some structure to the message, identifying the sender's name, location (to the extent possible), and category of the message - a missing persons report, a request for assistance, etc. The message will go into a Ushahidi GeoRSS feed that will be captured by Sahana and fed into a simple Request Management system where the requests for assistance (such as "send water" to a certain village or neighborhood) can be made visible to relief organizations working on the ground. Organizations can fulfill or claim requests for handling and message the person back that assistance is coming. (Missing persons information will be captured by Google).

5. Translation: In addition, our translation project is now set up for Kreol and French translation and we may utilize a pool of Kreol-speaking volunteers being set up by the Service Employees International Union (SEIU) to help in these efforts. Interested translators should be directed initially to:
http://translate.hfoss.eu/wiki/Translation to become oriented in the process.

6. Shelter Registry and Disaster Victims Registry: In the coming days, we expect that there will be a requirement to start tracking the location of temporary shelters now being established, and possible registration of the survivors. We will prepare Sahana's existing registries for such purposes, which will produce further consumable data layers as well as additional missing persons reconciliation capabilities.

If you want to help:

We are using the IRC #sahana channel on freenode as our main coordination tool. Join the chat room to volunteer for tasks and someone from our core volunteer team will direct you - this room is actively staffed on a 24x7 basis.

But first, please check out the wiki pages to see what are the current requirements and areas of focus. We have a lot of volunteer Python and PHP programmers already working on the codebase, but we can probably use more. Please review the requirements page in particular to see where you might help.

We also have a large need for non-technical help - particularly for documentation support - user guidelines and instructions in particular - including some nice screenshots.

...

Finally, we could use help maintaining our own wiki - both the main page and requirements... much of this can be culled from the chat room logs - and helping to update some of the common public repositories of information about similar efforts, such as the crisis commons wiki at
https://crisiscommons.org/, although they are doing a pretty good job at tracking us ourselves.

Remember to add yourself to the wiki as part of team, and what you are doing.

Acknowledgements

Personally, I have never been a part of such a collaborative and cooperative effort on the part of different organizations to come together and to help each other and to not replicate efforts. The Sahana community has worked closely and constantly with InSTEDD, Ushahidi, haitianquake.com, Google, the Crisis Camp participants, and others I apologize for not mentioning and we wouldn't have been able to accomplish all that we have without this, and for this I am very grateful.

The around the clock efforts of many of the Sahana community are too numerous to mention here, and at risk of leaving anyone out, I would just like to thank everyone for all that they have done and been able to do while juggling responsibilities such as full-time jobs and families.

This has been a new model for Sahana deployments - rather than waiting for a specific customer to come forward to take ownership of Sahana, we have self-deployed and I think this will be a likely successful model for the future. More and more, technology projects are stepping forward and doing good directly.

So go forth and do good.

Best regards,
Mark
==========
Mark Prutsalis
President & CEO
Sahana Software Foundation

Drupalcon London - Day 3 Weds. Tom Standage keynote, sessions, + BoF ...

Wednesday was a funny day at Drupalcon - literally. The cuppa tea at break was truly divine and delivered with that quintessential British style - very traditional.

At the morning's keynote Tom Standage of The Economist gave us an insightful and historical perspective on social media. This took in the Romans and their scribes (photo below and video), Martin Luther and English Civil War and America's fight for independence. There's  a book to follow. Given the emphasis on ethnography and anthropology in successful informatics - IT we should always be open to the lessons of history, but not constrained by it.

(Videos are appearing online now). My session pick started with Multilingual Drupal Solutions: Use Cases and Modules. This isn't the first session on this topic I've attended, but it was a helpful update - especially the use cases and modules. After dinner Jeff Noyes is clearly clued in on Creating and Measuring the User Experience. This is a must do, with a real potential dividend, but for hobbyists like me it was encouraging to hear Jeff describe a range of resources that included DIY testing.

Early on Jeff noted  the benefit of having a project charter - so last evening I started  one. Basically, what are my projects aims. Actually a things other things emerged from doing this.

I slipped up with node.js and Drupal, great stuff I'm sure but rather beyond me in terms of need and understanding. The principles were a good take home. For the final session the meeting on theming was packed out, so I headed to a BoF pivotal for the Drupal documentation team:

Doing Multiformat publishing & single source content with DITA in Drupal - status and roadmap

It's been a bit more than a year now that we started working on a DITA module for Drupal. In this session we'll review the current status, talk about the good & the bad and look forward to what we are going to be doing in Drupal 7.

DITA (Darwin Information Type Architecture) is an Oasis XML standard started at IBM that has become a major standard in enterprise technical communication. It's used in industries with modular products to publish documentation in a range of formats in minutes in stead of days while saving up to 60% of translation costs.

My new site requires new data items and on Tuesday after Entities - Emerging Patterns of Usage this was given as a key use case for entities. Of course 'entities' have been around ages in RDBSes (1969), but in Drupal they have a specific status now (a dialogue that also seems to bring in nodes, fields and taxonomy). The DITA BoF proved very relevant to me and h2cm as a health and social care -

• website;
• learning experience;
• application (!) 

- demands documentation. Not only that but standards based documentation (and classification system(s)). There's another BoF this dinner time - I'll try and get there.

Drupal's documentation is a recognised mess, hence the investment in DITA and seeking a solution. Back in Szeged 2008 I remember sitting down on that final code sprint day. I had it in mind to read some stuff and try and contribute. I do have an eye for docs. Well, I've been Editor here since April 2006. Previously (1995 - 2007) I read through and reviewed data definitions and information standards (and not just proof reading). In 2008 though I couldn't focus (really as I found out a year later). Maybe it wasn't just me! One thing: the next monitor I purchase will be optimised for text and portrait, or is that old hat these days? 


With RDF, translation, and modules like Features, Panels, Entities, DITA, Organic Groups, Context ... there are so many lucky dice to play; but there is no single roll that proves a winner: there are several!


My photo: c/o the keynote speaker Tom Standage who stated the image has not been altered in what it represents.

'Thinking outside the box ...' iii by Amber Javis

Third response to a blog post by Amber Jarvis on The Mental Elf:

Thinking outside the box: alternatives to standard inpatient mental health care

Amber's post considers a study by:

Griffiths, J. L., Baldwin, H., Vasikaran, J., Jarvis, R., Pillutla, R., Saunders, K. R., … & Johnson, S. (2025). Alternative approaches to standard inpatient mental health care: development of a typology of service models. International Journal of Mental Health Systems, 19(1), 1-13: https://pubmed.ncbi.nlm.nih.gov/40247283/

A Community Psychiatric Nurse since 1985, on first contact patients were often upset initially at the prospect of a visit. Not the fact it was a nurse, but a psychiatric, 'mental' nurse. If the patient was OK about it, their family may have had qualms. Discretion was always exercised, essential in terms of maintaining confidentialty. Not infrequently, as a team we had a conflict of interest. A colleague already had a client a few doors down; or they lived around the corner. Socio-politically, there was never an issue back then with shop fronts, but homelessness has a long history of course. I've worked in intermediate support, visiting someone 2-3 times in a day. That continuity helps, in contrast to the experience of older adults in social care. It could be that the potential stigma elicited by intensive home care is now attenuated by:

• The public's increased awareness mental health & illness;
• The fragmentation of neighbourliness means people really aren't interested?

In the conclusion on Griffith's et al's study Amber notes:

'The authors’ classification of alternative service models could help planners and commissioners understand ‘the whole range of options’ when deciding which improvements to prioritise and invest in.

However, future studies should investigate the implementation challenges surrounding these alternative models – that is, what might make certain models easier or more difficult to introduce? Research investigating their effectiveness in practice is also required – are there particular models that are better suited to certain individuals, at particular times? As the authors put it: “what works best for whom, when and how”!'

The government in England has launched a trial regards people who are sick, and their work status:

'GP surgeries in England can offer advice to patients on getting back to work, including career coaching or exercise classes, as part of a pilot project to reduce the number of people who are signed off work sick.

The aim is to help people return to the workplace more quickly to reduce the length of time they need fit notes - better known as sick notes.

These are issued by health professionals if a patient is unwell or cannot work for more than seven days.

A total of £1.5m is being made available to 15 regions in England, and will be shared between GP practices in these areas to hire coaches or occupational therapists to support patients in their return to work.'

Hugh Pym, Health editor: https://www.bbc.co.uk/news/articles/cwyx880d1w8o 

Individual

|

      INTERPERSONAL    :     SCIENCES               

HUMANISTIC  --------------------------------------  MECHANISTIC      

 SOCIOLOGY  :    POLITICAL 

|

Group

Career coaching Exercise classes Counselling Reduce time spent 'ill - sick - off-work' Motivation - Mindset	FIT - SICK: physically only of course! Seven days What can't I do? What can I do?
Social Prescribing Occupational Therapists Physiotherapist Support workers Horticultural groups Local history	FIT NOTES - SICK NOTES £1.5m across 15 regions Policy Welfare budget Behavioural Economics Integrated Care & Social Policy

Given the rise of mental health related provblems in the population, some might argue that increased awareness of, and education about mental illnesses is part of the problem. But this isn't literacy then?

With the standing of the mental health nursing curriculum called into question, policymakers have some serious decisions to make. Social prescribers and care navigators are not the only people preoccupied with signposting. Griffith et al. write:

'Inpatient care is also costly; even though only 3% of people in England accessing mental health care in 2018/19 received inpatient mental health care, National Health Service (NHS) trusts in England still invest more in inpatient than community services [8].'

Hodges' model: Axes & Domains

You can appreciate just how far away prevention and a health literate population truly are. Budgets will have to be re-directed. Now that is 'care-ordination'.

Griffith et al. and Amber's response, calls care that is simultaneous person-centred and service-centred. 

In Hodges' model it is as if the vertical axis, is turned and the 'individual' aligned with the humanistic (person-centred) and group - the mechanistic (service-centred) axis. This gives us self-care, individualised healthcare, personalised medicine through to population health.

Griffith does not venture into literacy and education (not their study's purpose, of course); but using Hodges' model, we can see two critical related issues. In addition to reducing the time a person is physically, and mentally indisposed, unwell, ill, sick ...

1. We need to improve the lot of children excluded from school;
2. Seriously address the determinants of health socio-politically.

'Thinking outside the box ...' i

ii 'Thinking outside the box ...'

memo FROM: Classroom health TO: Global health - PSHE education and model standards

Health care and educational professionals learn and adopt the key tools of the trade whilst training. Although for several decades experiential learning has also gained recognition and weight, it is the learning of theory and relation to practice in basic training that shapes the future career. We can describe this as formative professional education. We then trust that this learning and the tools in use are updated according to research, evidence and best practice. There is much navel gazing at present as to how to measure, nurture, instill and strengthen the character trait of compassion. This applies not only to children, but within nursing.

This issue highlights of course what students bring with them to the lecture theatre, clinical arena and what they take from there to carry them through their professional career. My ideal would be that students have already learned and used Hodges' model as 14-16 year old's, as they negotiate their personal, social, health and economic (PSHE) education.

While Hodges' model is a world away from a de jure standard
- that is, defined and enforced by the ISO -
it might just :) become a de facto standard,
because of its widespread adoption in and beyond the classroom.

There is a great opportunity here for Hodges' model in the UK as PSHE education becomes compulsory in 2011. Perhaps you can help in or beyond the UK?

Reference:
Mooney, H. (2009). Can you measure compassion?, Nursing Times, 21 April 2009.

Blog post inspired by adamatronics groups.drupal.org Drupal in Education: Joint effort on a D6 SCORM API

tags: 'preventive medicine' + 'preventive medical sociology'?