Rama Nurse Public Policy

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  • ผาสุก พงษ์ไพจิตร (2536) แบ่งคนชั้นกลางเป็น 4 กลุ่มคือ (1) นักวิชาชีพผู้จัดการ ผู้บริหาร (2) กลุ่มพี่น้อง (3) คนงาน คอปกขาวระดับล่าง (4) นักคิดและนักวิชาการ
  • Rama Nurse Public Policy

    1. 1. นพ. ชูชัย ศรชำนิ chuchai.s@nhso.go.th chuchai.sn@gmail.com Facebook ,Twitter : Morchuchai 1
    2. 2.  a course of action or inaction (Heclo 1972)  a course of action adopted and pursued by a government, party, rulers, statesman (Oxford English Dictionary)  a set of interrelated decisions … concerning the selection of goals and the means of achieving them within a specified situation … (Jenkins 1978)  decisions taken by those with authority and responsibility for a given policy area (Buse et al 2005) any course of action followed primarily because it is expedient or advantages in a material sense 2
    3. 3.  นโยบายด้านสาธารณสุข (Public Policy) นโยบายเพื่อการดาเนิน สาธารณสุข ที่เป็นเรื่องที่เกี่ยวข้องทางด้านสุขภาพโดยตรง  นโยบายสาธารณะเพื่อสุขภาพ (Healthy Public Policy) นโยบาย สาธารณะที่แสดงความห่วงใยอย่างชัดเจนในเรื่องสุขภาพ พร้อมที่จะรับผิดชอบ ต่อผลกระทบทางสุขภาพ ที่อาจเกิดขึ้นจากนโยบายนั้น ขณะเดียวกันก็เป็น นโยบายที่มุ่งสร้างเสริมสิ่งแวดล้อมทั้งทางสังคม และกายภาพที่เอื้อต่อการมีชีวิตที่ มีสุขภาพดี และมุ่งให้ประชาชนมีทางเลือก และสามารถเข้าถึงทางเลือกที่ ก่อให้เกิดสุขภาพดีได้
    4. 4. 4 • นโยบำยของรัฐบำล-แถลงกำรณ์ของนำยกฯ • กฎหมำย พรบ พรก กฎกระทรวง ประกำศ • แผนพัฒนำเศรษฐกิจและสังคมแห่งชำติ • แผนแม่บทแห่งชำติ • บัญชียำหลักแห่งชำติ • ชุดสิทธิประโยชน์ของระบบประกันสุขภำพ • กฎหมำย กฎระเบียบในระดับจังหวัด • แนวทำงระดับเขตตรวจรำชกำร • มติของคณะกรรมกำรจังหวัด อำเภอ • แนวทำงกำรคัดเลือกเวชภัณฑ์ของโรงพยำบำล • Clinical Practice Guidelines, Standard Operating Procedures (SOP) เช่น Laboratory manuals •กำรจัดงำนประชุมวิชำกำร นโยบำยระดับชำติ นโยบำยระดับพื้นที่ นโยบำยระดับองค์กร
    5. 5. 5 Input Process By product Input Human resources Financial resources Instruments Technical knowledge Output Outcome Effect Impact Short term Long term
    6. 6. 6 Walt G and Gilson L, Reforming the health sector in developing countries: the central role of policy analysis, Health Policy and Planning 1994; 9: 353-70 Actors Context Content Process
    7. 7. ฉุกเฉิน โรค เรื้อรัง สุขภาพจิต พัฒนาการ เด็ก ผู้สูงอายุ ฟื้ นฟูผู้ พิการ วัยรุ่น ภาคี สุขภาพ มูลนิธิสาธารณสุขแห่งชาติ 2553
    8. 8. Performance framework (WHO, 2000)
    9. 9. Source: World Health Organization. Everybody’s Business: Strengthening health systems to improve health outcomes—WHO’s Framework for Action. Geneva: WHO, 2007, page 3.
    10. 10. Health Policy and Healthy Public Policy Development Diseases or Service Response Health System Response
    11. 11. . . . .  Insurance Model  Utilization review, quality assurance function  Compliance and access orientation  No integration  Care Delivery Model  Develop standard tools: CPG, care map  Linear integration  Security (Continuum Care) Model  Community health care, optimum care site  Continuous quality improvement  Promote wellness and community health status  Multidimensional integration 12
    12. 12. พัฒนาการทางเศรษฐกิจ สังคม เทคโนโลยี กับ การพัฒนานโยบายความเข้มแข็งระบบสาธารณสุข “โรคเรื้อรัง”
    13. 13. 2005
    14. 14. Generation 2010 2020 2030 Baby Boomer ( 50 ปี ขึ้นไป) 6,462 - - Gen X (31 - 49 ปี) 15,742 15,742 - Gen Y (18 - 30 ปี) 3,750 3,750 3,750 Gen M - 6,462 22,204
    15. 15. Prevalence Hypertension: 23% male, 21% female All samples are hypertensive, >140/90 mmHg, Effective coverage of hypertension, adult >15 yr. 2003 Source: National Health Exam Survey 6 12 11 19 5 5 77 64 0% 20% 40% 60% 80% 100% Male (N=7,544) Female (N=7,580) treated + well control Treated, not well controlled Diagnosed, no treatment Not diagnosed
    16. 16. Prevalence DM: 6% male, 7% female All samples have FBS, >126 mg/dl Effective coverage of DM, adult >15yr. 2003 Source: National Health Exam Survey 9 15 24 34 2 2 66 49 0% 20% 40% 60% 80% 100% Male (N=2,045) Female (N=2,601) treated + well control Treated, not well controlled Diagnosed, no treatment Not diagnosed
    17. 17. 19 คนชั้นกลางในไทยปี 2533-2549 0 2 4 6 8 10 12 14 16 2529 2531 2533 2535 2537 2539 2541 2542 2543 2544 2545 2547 2549 2550 69-346 บาท/วัน เส้นความยากจน-346 บาท/วัน จานวนครัวเรือนชั้นกลาง แยกตาม 2 นิยามจานวนคนชั้นกลางอยู่ระหว่างนิยามทั้ง สอง คือ 12-15 ล้านครัวเรือน
    18. 18. 20 ร้อยละครัวเรือนทุกกลุ่มทีมีอุปกรณ์อานวยความสะดวก เทศบาล นอกเทศบาล 17.59 21.19 22.89 26.74 57.71 60.77 68.02 78.51 85.73 88.14 91.04 96.44 0 20 40 60 80 100 รถยนต์ส่วนบุคคล รถบรรทุกเล็ก / รถปิกอัพ / รถตู้ เตาอบไมโครเวฟ เครื่องปรับอากาศ เครื่องซักผ ้า รถจักรยานยนต์ วิทยุ เครื่องเล่นวีดีโอ / วีซีดี / ดีวีดี ตู้เย็น โทรศัพท์เคลื่อนที่ หม ้อหุงต ้มอาหาร โทรทัศน์ 4.81 5.19 7.12 19.70 41.56 56.64 66.63 74.54 77.68 81.77 83.01 94.71 0 20 40 60 80 100 รถยนต์ส่วนบุคคล เครื่องปรับอากาศ เตาอบไมโครเวฟ รถบรรทุกเล็ก / รถปิกอัพ / รถตู้ เครื่องซักผ ้า วิทยุ เครื่องเล่นวีดีโอ / วีซีดี / ดีวีดี โทรศัพท์เคลื่อนที่ รถจักรยานยนต์ หม ้อหุงต ้มอาหาร ตู้เย็น โทรทัศน์ ความต้องการสิ่งอานวยความสะดวกทาให้ตลาดสินค้าอุปโภค บริโภคใหญ่และขยายตัว เช่น เครื่องใช้ไฟฟ้า ยานพาหนะ อาหาร แปรรูป เกิดการผลิตและการจ้างงานในประเทศ ครัวเรือนมีค่าใช้จ่ายที่เกี่ยวข้องกับ การเรียนรู้เพิ่มมากขึ้น เช่น ด้านการสื่อสาร และการ เดินทางในโอกาสพิเศษ รวมทั้งการลงทุนด้าน คอมพิวเตอร์และเชื่อมต่ออินเทอร์เน็ต
    19. 19. 2533 2539 2540 2541 2543 2547 การบริโภครวม 65.9 62.8 62.6 63.3 63.2 63.6 • ภาคเอกชน 57.1 54.4 54.4 53.8 54.0 54.9 • ภาครัฐบาล 8.8 8.4 8.2 9.6 9.2 8.6 การลงทุนรวม 39.1 42.5 34.2 21.3 19.9 22.5 • ภาคเอกชน 33.2 32.1 22.7 12.1 12.5 16.4 • ภาครัฐ 5.9 10.4 11.6 9.2 7.4 6.1 ส่งออกสินค้าและบริการ 36.5 42.0 45.7 55.3 64.7 65.7 นาเข้าสินค้าและบริการ 41.54 49.2 44.3 38.8 49.8 54.0 ที่มำ : สศช.
    20. 20. ข้อมูล สำนักงำนคณะกรรมกำรอ้อยและน้ำตำล คัดจำกรำยงำนกำรสำธำรณสุขไทย พ.ศ. 2544-2547
    21. 21. % of Total 52.61 42.83 Rank Disease DALY ('000) % % DALY ('000) Disease 1 HIV/AIDS 645 11.3 7.4 313 Stroke 2 Traffic accidents 584 10.2 6.9 291 HIV/AIDS 3 Stroke 332 5.8 6.4 271 Diabetes 4 Alcohol dependence/harmful use 332 5.8 4.6 191 Depression 5 Liver and bile duct cancer 280 4.9 3.4 142 Ischaemic heart disease 6 COPD 187 3.3 3.0 125 Traffic accidents 7 Ischaemic heart disease 184 3.2 3.0 124 Liver and bile duct cancer 8 Diabetes 175 3.1 2.8 118 Osteoarthritis 9 Cirrhosis 144 2.5 2.7 115 COPD 10 Depression 137 2.4 2.6 111 Cataracts Male Female DALY
    22. 22. 9.4% 8.1% 5.7% 5.5% 4.5% 3.7% 2.2% 1.7% 1.3% 0.9% 0.9% 0.5% 0.3% 0.3% 0.2% 13.8% 5.8% 5.1% 5.0% 4.2% 3.9% 2.3% 1.4% 1.2% 3.6% 1.4% 0.7% 0.7% 0.4% 0.3% 0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 16.0% Unsafe sex Alcohol Tobacco Blood pressure Not wearing helmet Obesity Cholesterol Fruit & vegies Physical inactivity Illicit drugs Air pollution Water & sanitation Malnutrition - int standard Not wearing seatbelt Malnutrition - Thai standard % of total burden 2004 1999 ลำดับปัจจัยเสี่ยงที่ก่อให้เกิดภำระโรคจำกมำกไปหำน้อย ได้แก่ กำรมี เพศสัมพันธ์ที่ไม่ปลอดภัย แอลกอฮอล์ บุหรี่ ควำมดันเลือดสูง กำรไม่ สวมหมวกและคำดเข็มขัดนิรภัย ภำวะน้ำหนักเกินและโรคอ้วน ระดับ โคเลสเตอรอลในเลือดสูง กำรบริโภคผักและผลไม้น้อย กำรขำดกำร ออกกำลังกำย กำรใช้สำรเสพติด มลพิษทำงอำกำศ กำรขำดน้ำสะอำด กำรสุขำภิบำลและสุขอนำมัยที่ไม่เหมำะสม และภำวะทุพโภชนำกำร
    23. 23.  “Knowledge is power”  Medical process: information process  Delocalised, distributed and direct  Decision support, information management, identity technology, imaging, visualisation, sensors, telemedicine  The home as treatment location  The Internet Patient
    24. 24.  Diagnosis, data analysis, reminders, memory empowerment, ”second opinion”  Interactive broschures, simulations, smart objects, ”the digital doctor”  Benefits patient participation, handle information overload  Problems: conservative, silent knowledge, integration with patients and organisation
    25. 25.  Scanning + fast visualization + information fusion  Non-invasive exploration  Direct information to doctors  Shorten the treatment chain, reduce sidetracks  Requires change in routines
    26. 26.  Trends  More conditions measurable, smaller, cheaper, plentiful, more functions per chip  More intimate and biological, both non-invasive and implanted  Active ”smart” sensors/actuators, wireless communication  Pathogen sensors, automated medication  Moves the location of diagnosis and treatment to the periphery  Information overload, privacy, security, training
    27. 27.  Surgery supported by information technology  Remote surgery  Direct visualisation  Augmented reality  Robotics  Economy? Stumbles on organisation issues
    28. 28.  More and more applications  Faster recovery  Faster surgery redistributes medical personell  Need of a new kind of operating theatre?  Strong link toVR and robotic surgery
    29. 29.  Regenerative medicine  Rational drug design  Bionics  Genetic testing  Vaccines  Enhancing medicine
    30. 30.  Rational design  Based on genomics, simulation and knowledge of basic processes  Generics threatened, business models in pharma threatened  Blurs the borders between palliative, curative, preventative and enhancing medicine
    31. 31.  Neurointerfaces rapid development (~300 electrodes, permanent)  Prosthetic research underfinanced  Large gains for small groups
    32. 32.  Cheap, fast genetic tests many conditions  How many wants to test? How does the health system respond?  Benefits: More individually adapted, good for preventative medicine and pharmacogenomics  Problems: Interpretation, too much faith in genetics, diagnosis develops faster than treatment, breaks information monopolies
    33. 33.  Reproduction as a right?  We are willing to spend enormous sums on our children and their health  Genetic testing, preventative medicine  Perinatal medicine
    34. 34.  Vaccines for treatment instead of just prevention  Immune system control  Vaccines against  Allergies  Diabetes  Autoimmune illnesses  Metabolic illnesses  Cancer  Narcotics
    35. 35.  The brain/mind increasingly visible  New pharmacology + understanding of brain leads to treatment of many mental disorders  Hybrid therapies
    36. 36.  NBIC convergence  Enhancement of previous technologies  Reduced price  Increased effectiveness  Increased portability  Active and smart devices and drugs  Development gradual and enabled by previous technologies.
    37. 37. Epping-Jordan, J E et al. Qual Saf Health Care 2004;13:299-305 Copyright ©2004 BMJ Publishing Group Ltd.
    38. 38. Population Screening Using claims/clinical data to identify patients for disease management Patient Risk Management Surveying patients about disease status/burden to identify for disease management Team-Based Care Using formalized teams to increase collaboration of care Alternative Encounters Providing opportunities outside of the face-to- face encounter for relationship Cross-Consortium Coordination Managing across sites and settings to improve care continuity Patient Education Teaching patients about their disease Outreach/Case Management Tracking patients and their status proactively Decision Support At the Point of Care Translating disease management guidelines to patients-specific recommendations for clinicians. Guidelines/Protocol Providing information to clinicians on recommended clinical management Performance Feedback Measuring performance in delivering desired care and achieving improved outcomes
    39. 39. Lifestyle interventions Low risk At risk Disease Management DiseaseSymptomsEarly Signs Preventive Services Case Management Screening Primary and Secondary Prevention Acute treatment Disease Management HEALTH IMPROVEMENT DISEASE MANAGEMENT HEALTH MANAGEMENT POPULATION-BASED CASE-BASED
    40. 40.  Primary care dominated by chronic illness care  Clinical and behavioral management increasingly effective BUT increasingly complex  Inadequate reimbursement and greater demand forcing primary care to increase throughput—the hamster wheel  Unhappy primary care clinicians leaving practice; trainees choosing other specialties  Loss of confidence in primary care by policy-makers and funders  But, there are new models of primary care and growing interest in changing physician payment to encourage and reward quality
    41. 41. World Health Report: 2008
    42. 42.  Coordinate with other partners - central government + local authority + community + private sector,  Working in community – home ward,  Proactive, outreach services based on community health needs,  Care coordination – horizontal and vertical levels and case management system
    43. 43.  A “continuous healing relationship” with a care team and practice system organized to meet their needs for:  EffectiveTreatment (clinical, behavioral, supportive),  Information and support for their self-management,  Systematic follow-up and assessment tailored to clinical severity,  More intensive management for those not meeting targets, and  Coordination of care across settings and professionals
    44. 44. Reviews of interventions in other conditions show that practice changes are similar across conditions Integrated changes with components directed at: use of non-physician team members, planned encounters, modern self-management support, Intensification of treatment care management for high risk patients electronic registries
    45. 45. Informed, Activated Patient Productive Interactions Prepared, Proactive PracticeTeam Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model
    46. 46. Informed, Activated Patient Productive Interactions Prepared Practice Team
    47. 47. Assessment of self-management goal attainment and confidence as well as clinical status Adherence to guidelines Tailoring of clinical management by stepped protocol (Treat to target) Collaborative goal-setting and problem-solving resulting in a shared care plan Planning for active, sustained follow-up Informed, Activated Patient Productive Interactions Prepared Practice Team How would I recognize a productive interaction?
    48. 48. Informed, Activated Patient They have goals and a plan to improve their health, and the motivation, information, skills, and confidence necessary to manage their illness well.
    49. 49. Goal To help patients take a more active role and be more competent managers of their health and healthcare.
    50. 50. Goal To help patients access effective and useful services and resources in the surrounding community.
    51. 51. Prepared Practice Team Practice team and interactions with patients organized to help patients reach clinical targets and self-management goals. .
    52. 52. Goal To organize practice staff, schedules and other systems to assure that all patients receive planned, evidence-based care.
    53. 53. Goal To assure that clinicians and other staff have the training, scientific information and system support to routinely provide evidence-based (adhere to guidelines) and patient-centered care.
    54. 54. Goal To assure that clinicians and other staff have ready access to patient information on individuals and populations to help plan, deliver and monitor care.
    55. 55. Goal To assure that practices within the organization have the motivation, support and resources needed to redesign their care systems.
    56. 56.  Practices spent considerable time searching for/developing tools  Some practices felt intimidated by taking on the whole model – asked for a sequence  Many changes were made in ways that were not sustainable logistically or financially (e.g., double data entry)  CCM elements implemented as “special events” rather than part of routine care  Many achieve process improvements but outcomes don’t change
    57. 57. Self-Management Support and Community Resources
    58. 58. Community, Environment, Policy Systems, Organizations, Businesses Family, Friends Peer Groups Individual
    59. 59. Self-Management Support Delivery System Design Decision Support Clinical Information System Health System Organization of Health Care Community Resource and Policies Informed, Activated Patient Prepared, Proactive Practice team Productive Interaction Functional and ClinicalOutcomes
    60. 60.  Provide reminders for providers and patients.  Identify relevant patient subpopulations for proactive care.  Facilitate individual patient care planning.  Share information with providers and patients.  Monitor performance of team and system.
    61. 61. Barriers to CIS use Lack of perceived value Competing business and productivity demands Lack of office flow expertise Lack of information support Lack of leadership support
    62. 62. Functionality! Whatever you use should be able to deliver information that supports: population planning clinical summaries at the visit individual care planning reminders performance feedback
    63. 63. be organized by patient; not disease, but responsive to disease populations contain data relevant to clinical practice assist with internal and external performance reporting guide clinical care first, measurement second!
    64. 64. Everyone, including senior leadership understands the clinical utility and supports the time involved in upkeep. Data forms are clear, data entry role is assigned, data review time allotted. Data entered and retrieved are clinically relevant, and used for patient care first, and measurement second. Data can be shared with patient to improve understanding of treatment plan.
    65. 65. Investors Customers Prospects Press/Analysts Partners Employees Potential Employees Influencers MESSAGES Competitors
    66. 66. No. Rank Country Number of Facebook users March 2009 Number of Facebook users 31st March 2010 12 month growth % 4 8 Philippines 1,026,300 11,561,740 1027% 5 15 India 1,561,000 7,809,800 400% 6 19 Malaysia 1,197,560 5,552,660 364% 7 23 Thailand 284,340 2,895,320 918% ศูนย์เทคโนโลยีสำรสนเทศและกำรสื่อสำร สำนักงำนปลัดกระทรวงคมนำคม Facebook usage statistics - March 2010 (with 12 month increase figures)
    67. 67.  จานวนผู้ใช้ Facebook ทั่วโลก 465,562,160 คน  จานวนผู้ใช้ Facebook ในประเทศไทย 3,757,340 คน คิดเป็น 0.81% ของทั่วโลก Female 2,069,440 55.8% Male 1,636,040 44.2% Thailand Male / Female ศูนย์เทคโนโลยีสำรสนเทศและกำรสื่อสำร สำนักงำนปลัดกระทรวงคมนำคม Facebook usage statistics - March 2010
    68. 68. <= 13 36,220 (1.8%) 14 – 17 271,980 (13.1%) 18 – 24 778,400 (37.6%) 25 – 34 714,840 (34.5%) 35 – 44 189,680 (9.2%) 45 – 54 54,820 (2.6%) 55 – 64 13,660 (0.7%) 65+ 9,780 (0.5%) Thailand Age Distribution ศูนย์เทคโนโลยีสำรสนเทศและกำรสื่อสำร สำนักงำนปลัดกระทรวงคมนำคม Facebook usage statistics - March 2010
    69. 69.  18 file and OPD individual record  HCIS , JHCIS, HosXP, etc.  Report for claim  New media , Social network  Tele consultation
    70. 70.  Blogs  Wikis  Facebook , twitter  Podcasts  Videocasts /Vlogs  Moblogs  MMS  Internet telephony i.e. skype™ Tools that facilitate:  Communication  Engagement  Transparency  Trust Tools that are:  Complementary to traditional communication activities  Used by organizations who recognize the social characteristics of effective communication
    71. 71.  Asymptomatic Screenings  Lifestyle Modifications  Cessation of Addictive Behaviors  Medical Regimen Compliance  PrecautionAdoption
    72. 72.  Health Information  Behavior change  Self-management  On-line communities  Decision support  Disease management  Healthcare tools Office of Disease Prevention and Health Promotion, DHHS. Expanding the Reach and Impact of Consumer e -HealthTools. 2006.
    73. 73.  Improve dietary habits  Increase physical activity levels  Reduce heavy drinking  Decrease disordered eating behaviors  Improve adherence to treatment protocols  Impact on health care utilization and costs? Office of Disease Prevention and Health Promotion, DHHS. Expanding the Reach and Impact of Consumer e -HealthTools. 2006.
    74. 74.  The appropriate model for obesity and weight management is tailored information according to design principles suggested by Social CognitiveTheory and the Social Marketing Model.  The health behaviors to target are self- monitoring of diet and physical activity.  The devices areWeb-enabled “smart” cellular telephones and wireless PDAs. JTTufano & BT Karras. Mobile eHealth Interventions for Obesity: ATimely Opportunity to Leverage ConvergenceTrends. Journal of Internet Medical Research 2005;7(5):e58).
    75. 75. ลาดับเตียงผู้ป่วย ฟอร์มในการลงข้อมูล หน้าต่างฟอร์มต่างๆ ข้อมูลผู้ป่วย
    76. 76.  Embed evidence-based guidelines into daily clinical practice.  Integrate specialist expertise and primary care.  Use proven provider education methods.  Share guidelines and information with patients.
    77. 77.  Evidence-based medicine is an approach to health care that promotes the collection, interpretation, and integration of valid, important and applicable evidence.  The best available evidence, moderated by patient circumstances and preferences, is applied to improve the quality of clinical judgments. McMaster University
    78. 78.  Customize guidelines to your setting  Embed in practice: able to influence real time decision-making Flow sheets with prompts Decision rules in EMR Share with patient Reminders in registry Standing orders  Have data to monitor care
    79. 79.  Often begins with lifestyle change or adaptation (eliminate triggers, lose weight, exercise more)  First choice medication  Either increase dose or add second medication, and so on  Includes referral guideline
    80. 80.  Shared care agreements  Alternating primary-specialty visits  Joint visits  Roving expert teams  On-call specialist  Via nurse case manager
    81. 81. Interactive, sequential opportunities in small groups or individual training  Academic detailing  Problem-based learning  Modeling (joint visits)
    82. 82.  Build knowledge over time  Include all clinic staff  Involve changing practice, not just acquiring knowledge Evans et al, Pediatrics 1997;99:157
    83. 83. Principles of CIS &DS
    84. 84. PBGH Evaluation of Consumer Decision SupportTools June 2007
    85. 85.  Stoplight tools  Expectations for care  Wallet cards  Web sites  Workbooks
    86. 86. Informed, Empowered Patient Productive Interactions Prepared, Proactive PracticeTeam Improved Outcomes Delivery System Design Decision Support Clinical Information Systems Self- Management Support Health System Resources and Policies Community Health Care Organization Chronic Care Model
    87. 87.  Workforce Development  Up front training and Admin Support  Professional development  Integration of Complementary Medicine  Micro system optimization
    88. 88.  Clinical  Doctor,  Nurse Case Manager  Support groups  Behavorist  Pharmacist, Nutrition, H. Ed.
    89. 89. Demand * Complex health problem *Explosion of knowledge and technology *Health care reform *Expand the scope of nursing Supply *Shortage of health care personnel, both quantity and quality *Malutilization especially nurse Unsafe both nurses and patients/clients

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