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By C. Hamid. Trinity Baptist College. 2018.

It was assumed that those who were sick consumed services and those who were well did not purchase 100 mg vantin amex. Not only does this assumption reflect a dated notion of health and illness vantin 200 mg mastercard, it also does not account for the vast amount of discre- tionary transactions that occur in healthcare purchase 200mg vantin overnight delivery. We now realize that the demand for health services is extremely elastic and that the level of demand can be influenced by a wide range of factors discount 200 mg vantin otc. Furthermore generic vantin 100 mg on line, we now realize that the demand for health services can be manipulated. This book cites many cases in which consumers were made aware of a service that they previously did not know existed. Indeed, many consumers have been convinced that they have a condition they did not know they suffered from. It has historically been felt that healthcare is such a necessity that individuals would find a way to pay for required services even if it meant going into debt. Furthermore, it could be argued that safety nets exist in various com- munities in the form of public health clinics, charity hospitals, and such facilities that would ensure that all health problems were taken care of in one way or another. We now realize that the ability to pay for care is a major considera- tion affecting the demand for healthcare goods and services. Admittedly, for elective procedures and other products not considered medically nec- 171 Consumers Customers Clients Healthcare Consum ers and Consum er Behavior Age 177 Attitude Essentials of Healthcare Marketing Healthcare Marketing Plans: From Strategy to Action New England Journal of Medicine Motivation and Personality, 2nd ed Health United States, 1998 Health United States, 2002 Marketing Health Services 201 Ways to Conceptualize Products 207 Healthcare products, like other products, experience a natural life cycle that includes four distinct stages: introduction, growth, maturity, and decline. For marketers an understanding of the stage of the product life cycle is critical. If the organization is primarily involved in provid- ing inpatient services, an appreciation of the point in the product life cycle where inpatient services can be placed is required. If a marketing plan is being devel- oped for a specific procedure, the point in the life cycle where this product resides must be determined. The first stage in the life cycle of a product is the introduction or market development stage. Because the product is likely to be inno- vative, most of the marketing effort is directed toward creating awareness and cultivat- ing early adopters in the market. At this stage there are relatively few competitors, and goods and services are not standardized. Entry into the market is relatively easy because there are few established players; the introduction of desktop computers in the 1980s is an example of this stage. At this point the industry has become established, and the good or service has been accepted by the market. Expansion is rapid as new cus- tomers are attracted and additional competitors enter the arena. Products or services become increasingly standardized, although enhancements may continue to contribute to product evolution. Marketing planning at this stage emphasizes differentiation of the organization, product, or service. The rapid growth of home health care during the 1980s provides an example of this type of expansion. At this point most of the potential customers have been captured and growth begins to trail off. Because few new customers are available, competition for existing customers increases. Product features and pricing are highly standardized, and little differentiation remains between competitors. The num- ber of competitors decreases as consolidation occurs among the various players in the market, and it becomes increasingly difficult for new players to enter the market. Marketing activities emphasize retaining existing customers or capturing competitors’ customers. Traditional hospital inpatient services are an example of a product that has reached the maturity stage. At this point there are three strategies for stretching the life of the product: (1) product modification, (2) market modification, and (3) product repositioning. Hospitals have attempted to employ all of these strategies in the face of product maturity. Hospitals have attempted to add goods or services to ensure that utilization does not continue to decline.

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Family Therapy Directives With this in mind buy vantin 200mg without prescription, it is time to turn from the traditional verbal family therapy cheap vantin 200mg visa, with its multitude of approaches buy vantin 200mg online, to family art therapy order vantin 200 mg with visa. Hanna Kwiatkowska (1978) is often referred to as the originator of family art ther- apy buy vantin 100 mg low cost. Through her extensive research with the National Institute of Mental Health, she developed three family art techniques. These consisted of art therapy directives combined with traditional verbal therapy, family art therapy as the primary treatment choice, and a family assessment compris- ing six distinct art tasks. Kwiatkowska said of these techniques: The families’ spontaneous art productions were intended to help family members and therapists to better understand the problems in the family, to clarify family members’ roles and perceptions of each other, and to con- stitute a therapeutically useful mode of expression and communication. Unfortunately, this collaborative approach, which in- cluded each member of the family regardless of age, is frequently over- looked in favor of traditional verbal family therapy. By way of example, Kor- ner and Brown’s study (cited in Lund, Zimmerman, & Haddock, 2002) surveyed 173 therapists and found that 40% never included children in family therapy sessions, while 31% invited children yet did not include them as participants. Because of this diversity, the incorporation of the entire family unit produces, out of necessity, interventions that require both cognitive and emotional considerations. With these considerations in mind, the interactive experience of art therapy and its inherent emo- tional expression allow symbolic communication between parents and children regardless of age or ability. Consequently, "when the two disci- plines, family therapy and art therapy, are integrated into family art ther- apy, they do so sharing theoretical frameworks of personality development, family systems, and the art therapy process" (Arrington, 2001, p. As with group therapy, the use of art media provides an opportunity for the clinician to watch as the familial dynamics unfold not merely on a ver- bal level but in a way that reveals the unconscious motivations, behaviors, and feelings that make up the family interactional patterns. And this sym- bolic communication, from a psychodynamic framework, is the focus of this chapter. Derivatives of the psychoanalytic school, dynamically ori- ented family art therapists are interested in both internal processes and in- 275 The Practice of Art Therapy teractional ones and place an emphasis on understanding and working with the unconscious mind. However, no discussion of psychodynamic family therapy is complete without a dialogue focused on transference reactions as agents of under- standing and change. In my practice I use an analysis of the transference from a here-and-now perspective. In this way, the patient-therapist rela- tionship becomes an integral aspect of therapy, not through scrutiny only of infantile conflict but through clients’ pervasive maladaptive relational patterns (Bauer, 1993). This rendering is an adap- tation of the Non-Verbal Family Art Task (Landgarten, 1987), in which the entire family draws on a single sheet of paper at predetermined times. The daughter, whom I will call Frances, had been referred to out-of- home placement due to increasingly aggressive, intrusive, and impulsive behaviors. My first individual meetings with Frances were met with loud resistance quickly followed by temper tantrums. I knew that she had been involved in therapy for many years and often utilized coping strategies of aggressive iso- lation when she felt she was under scrutiny. Family Therapy Directives validate the anxiety by commenting aloud on our relationship, effectively bringing the acting-out behavior into a conscious realm where we could explore it. Roughly 1 month after beginning individual therapy, Frances was able to attend to the sessions without regression. However, I did not begin fam- ily art therapy sessions until 3 months later because it was important to build a strong therapeutic alliance based upon process illumination, con- tainment, and ego-enhancing directives to develop awareness. Throughout the task, Frances frequently made comments like "Don’t look" or "Don’t watch me. Frances’s form items are gath- ered into the center of the mural, while her mother’s drawings surround them in a metaphor of protection and enmeshment. As with other art therapy techniques, a family mural drawing allows the participants to be both contributor and observer. This provides the thera- peutic hour with rich clinical material that in many ways is incontrovert- ible. This symbolic communication metaphorically parallels the interac- tional patterns of the entire family. Moreover, the artwork’s permanency lends itself particularly well to interpreting transference reactions, as the artwork provides a tangible object that gives meaning to the experience as well as the interpretation. In these ways, the family art mural provides the mental health clinician with both interrelational examples and intra- psychic concerns that are often disguised in purely verbal communication.

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Another site purchase vantin 200mg with amex, having experienced turnover of one-half of its staff during the demonstration buy 100 mg vantin otc, integrated an introduction to the low back pain guideline into its two-day orientation to the hospital for newcomers buy vantin 200mg visa. None of the sites held formal training sessions for nurses buy discount vantin 100 mg line, medics best 100 mg vantin, PAs, or other ancillary staff involved in the treatment of low back pain patients. In most cases, these staff were simply instructed to ask patients to fill out their portion of form 695-R and, at some sites, to hand out a patient education pamphlet. Only about one-half of the ancillary staff that participated in our focus groups reported they had been introduced to the guideline. This omission contributed to reluctance by clinic staff at some sites to cooperate in using the guideline. To ensure use of conservative treat- ment for acute low back pain patients, all sites attempted to use the encounter form 695-R to support implementation of the guideline and ensure documentation of diagnosis and treatment. Compliance varied across the sites, however, depending on the support availabil- Implementation Actions by the Demonstration Sites 63 ity and frequency of rotation of ancillary staff, acceptance of the form by primary care providers, and aggressiveness of monitoring. Typically, a low back pain patient was identified at the sign-in desk or in the screening room. Clinic staff filled in the vital signs section and attached the form to the medical chart for the provider’s use. Com- pliance with this relatively simple procedure varied initially from 20 percent at some clinics to 92 percent at some TMCs, and most sites reported that compliance decreased over time. First, it was not clear to the sites whether MEDCOM mandated use of the form or gave the sites the discretion to decide whether and how to use it. MEDCOM clarified that the sites were expected to document the diagnosis and treatment of low back pain patients appropriately in the medical chart, but they could choose how to do that. The form 695-R was provided as a tool that would achieve appropriate documentation, but they were not required to use it. In response to this guidance, the sites tended to leave to the individual providers the decision about whether to use form 695-R. A second reason for low compliance in using form 695-R is that many providers were not satisfied with the contents of the form, and in particular, many complained that the form did not provide enough space to write notes. Overall, most physicians reported they used the form at the first visit (65 percent of providers in the focus groups), but only 20 percent used it at subsequent visits or for patients pre- senting with multiple problems. Providers felt that filling out the form at each return visit was duplicative and unnecessary. At one site, physicians had all but stopped using the form by the time of our last visit. Lack of standardization among providers within one clinic or TMC in use of the form made the processing of patients confusing for the ancillary staff. Third, many ancillary staff perceived that the documentation form added to an already heavy workload, and, hence, they were reluctant to use it. Ironically, about two-thirds of the ancillary staff that partic- ipated in our focus groups and had used the form reported that it shortened processing time (45 percent) or made no difference 64 Evaluation of the Low Back Pain Practice Guideline Implementation (22 percent). Some providers reported they did not insist the form be included with the patient’s chart because they knew the ancillary staff were overworked and they did not like placing new demands on them. The relatively high rotation of ancillary staff, particularly at TMCs, also contributed to low compliance with use of form 695-R. The sites did not act forcefully to maintain adequate levels of staff training regarding procedures for use of the form. Finally, some TMCs and clinics reported they ran out of forms and did not know how to replace them. MEDCOM did not set down procedures for ordering new supplies until later in the demonstration. This administrative barrier for providers and clinic staff discouraged use of the form yet further. AMEDD regulations state that only the SF-600 form can be placed in chronological order in the patient chart. Providers at some sites ex- pressed frustration at having to search for the form in the chart. Seeking to overcome some of these difficulties, one site spent con- siderable staff time to develop an automated form 695-R.

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As these were ill received (often left behind at the end of the session or thrown away as group members exited) purchase 100 mg vantin otc, she experi- enced feelings of shame generic vantin 200 mg line. As Yalom has stated cheap 100 mg vantin with visa, "the high discloser is then placed in a position of such great vulnerability in the group that he or she often chooses to flee" (1985 discount vantin 100mg fast delivery, p 100 mg vantin mastercard. For this female the stress became un- bearable, and she eventually retreated into the safety and confinement of her mental illness. I contend that, as with all psychotic thought processing, the delusions are never far from the individual’s internal truths. Thus, these disorganized and often nonsensical admissions can offer us a plethora of information when we pay attention to them. The drawing focused on a pregnant woman who is protecting her unborn child from the secondhand smoke of the father. Sally whispered the mother’s written comments ("you are not going to kill my baby") aloud and only paused when a helicopter flew over- head, at which point she said, "Helicopters save. For these reasons, I integrated this symbolic communication into the discussion and feedback. Additionally, it was clear that the group was counterproductive to Sally’s needs, and the ultimate self-disclosure of the drawing was her metaphorical request for protection and safety from the threatening ele- 269 The Practice of Art Therapy ments in her environment. As a result, with Sally’s involvement, she was provided a psychopharmacological review and placed in a group setting that could support her needs, decrease her isolation, and offer an experi- ence of success. When dealing with the difficult-to-treat client, incorporating self- disclosure directives is an invaluable tool in interpersonal learning and in- teraction. A directive that I particularly enjoy centers on issues related to comfort, care, and safety. Thus, if we are to work toward the objectives of belonging, competency, and esteem, the path often begins with security. The right side of the image represents the library where he could read in soli- tude. However, when asked where he was in the drawing (on the left side) he replied, "I’m walking around the cabin. This male had no safe place; even in idyllic surroundings his feelings of isolation, alienation, and insecurity were profoundly devastating. In another example of a self-disclosure directive based on safety and se- curity, Figure 6. In the discussion phase he wove a story in which his safe room was filled with four football fields of cars, which were all organized by type. Recalling the time spent on fortifying his doorway, I asked about the horizontal strip. It was at this point that he described an elaborate security system that re- quired a password both when one entered and when one left. The other group members were enraptured with his description, and "ooh’s" and "ahh’s" were clearly audible. As he was the only client to add safety measures in such a concrete man- ner, I took this addition as a demonstration of his intense need to control 6. For that reason, during the process of illumination my questions focused on trusting and the ex- pression of feelings (e. This client had recently been separated from her biological and ex- tended family due to multiple deaths. Her most vivid recollection was the time spent at the hotel pool, which she rendered to the right of the page. While relating the memory, her affect visibly shifted from pleasur- able reminiscence to grief-stricken pain. Group members acknowledged this genuine emotion in the most empathic manner possible: They lis- tened. She expressed this anger of loss by gathering a variety of markers and swiftly bringing them down on the page, effectively covering the heavens with the grief of her suffering. The vulnerability she expressed in her self-disclosure was instrumental in creating a greater group understanding and acceptance of her often con- flictual emotions of grief. Appendix G offers the clinician a list of sample directives divided into the types of structured exercises we have discussed: here-and-now inter- ventions, empathy, personal change, and self-disclosure.

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