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The scarcity of human resources is a factor that hampered the improvement of mental health (MH) services in Portugal. MH teams continue to rely on a small number of psychologists, nurses, social workers, occupational therapists and other non-medical professionals, with most teams maintaining traditional models care delivery. Nevertheless teams continue to evolve to ameliorate MH care considering present patients needs and effective treatments.
Windows 7 Ultimate with Service Pack 1 (x86) - DVD (Portuguese-P crack
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The study was carried out at public and private MH services in mainland Portugal. Profiles were assessed by survey method related with two dimensions: 1 - services characteristics and 2 - workforce profile.
Assessment of services showed: liaison with primary health care (56%), routine use of guidelines (57%), use of individual care plans (46%), inservice research (25%). Regarding workforce, 19% of the teams still rely on 2 professional groups (Psychiatrist and Nurse), 88% do regular training, 60% reported use of case management models, but only 16% had formal training on the model.
Despite the incremental inclusion of MH care essential components associated with services modernisation, Portuguese mental health teams still struggle to provide integrated care with the contribution of multiple professional groups in a multidisciplinary framework. This is specially true in the interior and rural areas of the country. Training programmes need to be maintained as a special priority by national and regional authorities to assure effective delivery of care.
The issuance of this visa supposes the attribution of a date of scheduling in the competent services, within the period of validity of 120 days of the visa, and it allows the applicant, after the formalization of the employment contract throughout that period, the right to apply for a residence permit. To do so, you must fulfil the general conditions for granting a temporary residence permit, under the terms of article 77 of the Law.
Telemedicine services are promoting more access to healthcare. Portugal was an early adopter of telemedicine to overcome both its geological barriers and the shortage of healthcare professionals. The Pediatric Cardiology Service (PCS) at Coimbra University Hospital Centre (CHUC) has been using telemedicine to increase access and coverage since 1998. Their Pediatric Telecardiology Service has been daily connecting CHUC with 13 other Portuguese national hospitals, and regularly connecting with Portuguese-speaking African countries, through a teleconsultation platform.
This study aims at exploring the Pediatric Telecardiology Service's evolution, through a comprehensive assessment of the PCS's development, evolution and impact in public health, to better understand the critical factors for implementation and sustainability of telemedicine, in the context of healthcare services digitalization. A case study was performed, with cost-benefit, critical factors and organizational culture assessment. Finally, the Kingdon's framework helped to understand the implementation and scale-up process and the role of policy-making.
PCS presents a dominant "Clan" culture. The Momentum's critical factors for telemedicine service implementation enabled us to understand how barriers were overcome (e.g. political forces). Willingness, perseverance and teamwork, allied with partnership with key stakeholders, were the foundation for professionals' engagement and service networking development. Its positive results, new regulations and the increasing support from the hospital board, set up a window of opportunity to establish a sustainable telemedicine service.
After 20 years, the telemedicine service of the Pediatric Cardiology Service (PCS) at Coimbra University Hospital Centre (CHUC) has enabled better coverage of the population within the central region of Portugal. A regular PCS's day encompasses several different opportunities where clinicians apply telemedicine: going from clinical observations at emergency level, to in-patient and out-patient teleconsultations for first diagnostic, observation or follow-up, referring to surgical interventions or treatment. PCS also cooperates with most Portuguese-speaking African countries (PALOP). The PCS's Telecardiology Service is probably one of the oldest telemedicine service running in the world.
The Portuguese NHS, like many other health systems, is facing a shortage of general practitioners1 (GP) and specialist physicians, such as Pediatric cardiologists [5]. NHS services' coverage is often aggravated due to the fact that most specialty services are kept in central hospitals, which are located along the country's coastline and distant from rural areas. Families living outside urban areas, have to deal with the problem of having to travel to attend consultations with specialists (e.g. for medical appointment, exam or treatment). Their travelling to central hospitals implies several additional costs, often putting the diagnostic confirmation and the follow-up at risk. The same scenario prevails in an emergency case. Emergency situations can often be tragic ones, with human lives loss. The lack of adequate transportation and the availability of services to stabilize the patient, or even of proper evacuation to the nearest hospital are quite frequent.
ICT systems, when well-integrated within the clinical context, can improve access to quality professional education and training, as well as access to healthcare services [7]. ICT enables a forward-looking planning approach, in a long-term perspective, addressing real needs of health systems and their human resources, moreover regarding pediatric cardiology [8]. Telemedicine ensures the delivery of healthcare services, where distance can be critical [9], and the decision-support (e.g. evacuations [10]) efficiently enhancing global health system management and ensuring that services issues are fully addressed. Telemedicine services can play an important role in the healthcare services' governance [11].
A cost-benefit analysis assessed both the cost impact for (1) the population (Eqs. 1.a and 1.b) and for (2) the healthcare system (Eqs. 2.a, 2.b and 2.c), to better inform decision-makers [24]. The cost analysis was based on the direct and indirect costs comparison, from 2007 to 2014. It was taken into consideration what the costs would be, with and without the intervention (the telemedicine service implementation), as well as the benefits for the patients, families, organizations and health system [25].
The selected organization's key-members were both the PCS's former and current director. The ICT director was also included due to the technology nature of the telemedicine service. The three have been in the organization since the inception of the telemedicine service. During the field study, a 30-min semi-structured interview was conducted with each key-member. This step was important to study the leadership's perception and expectations for further developments. The interviews were also important to identify the different stakeholders in the telemedicine agenda setting, and their roles in it.
A questionnaire OCAI [16], was answered by several members of the PCS team, as the first part of the CVF framework [17, 19], enabling the organizational culture assessment and the CVF analysis. It was returned by 15 PCS team-members, aged 26-66 years-old (median: 37.0; Interquartile range, IQR: 32.5-49.0), 60% female. The questionnaire was completed by all team members during the service weekly meeting. They were mainly pediatric cardiologists with different functions and responsibilities, diagnostic and therapeutic technicians and an administrative assistant. It took each about 10 min to answer the questionnaire.
To study the role of policy in developing the telecardiology service, the Kingdon's windows of opportunity framework [20] was applied. This methodology was previously validated for the Portuguese healthcare context [21].
A comprehensive methodological framework was set at three levels: (I) the case-study review, based on data collection, (II) the telemedicine service and organizational culture assessment based on combining the Momentum and the Competing Values (CVF) frameworks, and finally (III) the Kingdon's framework, for better understanding the windows of opportunity determinants for the telemedicine evolution.
Telemedicine's original idea occurred during a visit to Mayo Clinic in the USA in 1995. This experience motivated the idea of using telemedicine to improve healthcare coverage in Portugal [5]. Later, Dr. Eduardo Castela (the PCS service's Director; and a Mayo Clinic trainee), shared his experience with LusitÃnia Fonseca, Portugal Telecom Engineer and Head of the Innovation Department. She immediately saw an opportunity there, and in 1998 the first telemedicine consultation was a reality.
The PCS performed, from 1998 to 2016, a total of 32,685 out-patient TC, with a pattern that follows an S-shape logistic growth curve (Fig. 3). Well-fitted to the data (correlation coefficient, r = 0.9997), the logistic curve shows the service's gradual (although rather slow) diffusion [23]. If the TC progression maintains this pace, its maximum grow, stated by the S-curve ceiling (estimated k of 44,250 TC), is only expected to happen in the future (about 2050).
Over the last decade, TC were responsible for about 35.4% of the total out-patients, provided by PCS (Table 1), with a predominance of first consultations (46.8% of the total first consultations). The 12.6% of subsequent consultations, for patients' follow-up and monitoring, shows the telemedicine service consolidation, which is critical indicator for specialized hospital care access.
In a more stratified analysis, it can be verified that all the six categories have the "Clan" culture as the dominant one. "Clan" is often the dominant culture in healthcare services [5]. The top score for the dominant characteristics (Table 4) indicates that people sees the service as a personal place, the team as a family and a strong sharing relation. "Organizational leadership" values for the "Now" moment points to a leadership that is such an example as tutor, facilitator and caring, followed with a perception of an entrepreneur and innovative leadership. This dimension suffers a change direction to the "Preferred" future, strongly valuing "Hierarchy" values, by having the vision of a leadership who develops itself into a control and efficiency direction. The "Strategic emphasis" dimension presents a very even values mix, once more being prevalent on the flexibility and discretion driver, based in the "Clan" and "Adhocracy" characteristics oriented to collaboration and creativity. This type of organizations emphasizes human development, facing new challenges and prospecting for opportunities, though. "Management of employees" and "Criteria of success" dimensions focus on teamwork, with a collaborative process in an integrated way. On the issue of the "Organizational glue", loyalty and mutual trust, valuing commitment, are the dominant perception, although with emphasis on results achievement and goal accomplishment.
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