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HP Financial Services
HP Asset Recovery
A clear line of sight through your lifecycle
IT retirement marks a critical point when companies can refresh data centers and complete the lifecycle of outdated assets. Even the savviest firms can become burdened by multiple business processes, a growing list of regulations, and outsourced asset recovery management that's less than transparent. Any combination of these factors makes it very difficult to maintain a comprehensive IT portfolio or comply with regulatory requirements.1
Companies must adhere to 160+ pieces of legislation for environmentally responsible IT removal and recycling. Each company must also follow its own set of best practices.
Is your asset recovery airtight?
In today's competitive marketplace, every enterprise needs a trusted partner that knows their standards. Once you embark on an asset recovery path, you and your vendor partner must tightly manage logistics. Successful IT retirement comes with tight management and transparent tracking.
Empower your business with a clear end-of-life journey
With a programmatic approach to asset recovery, you can stay in control of your IT lifecycle and your organization's reputation. We will help you develop an enterprise-wide plan so you can track each asset from packing and shipping to processing and recycling.
Call on a trusted partner to help you stay in control of your IT assets.
Stay in control: Simplify Enterprise IT Asset Recovery
1 Updated Q4 2011: Cover Your Assets; Use IT Asset Life-Cycle Management To Control IT Costs, 2011
Financing and service offerings available through Hewlett-Packard Financial Services Company and its subsidiaries and affiliates (collectively HPFSC) in certain countries and is subject to credit approval and execution of standard HPFSC documentation. Rates and terms are based on customer's credit rating, offering types, services and/or equipment type and options. Not all customers may qualify. Not all services or offers are available in all countries. Other restrictions may apply. HPFSC reserves the right to change or cancel this program at any time without notice.

subset: commoncrawl


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Ben is an assistant curator currently researching the collections of wealthy Melbourne wool merchant and art collector, John Twycross, for an upcoming book and online exhibition. On the weekends, he likes to wander through grand gardens and restore his 1920s State Savings Bank bungalow home.
Returning to Melbourne following an impromptu drive up Mount Macedon, I stopped at Forest Glade, one of the mountain's well-known private gardens that is open to the public. Barely had I gone a few steps through the garden's cast iron gates when I recognised a very familiar sculptural group. I rushed forward and had my suspicions confirmed.
Alfred Jacquemart's Huntsman and Dogs, cast by Val d'Osne c.1879, in the Forest Glade private gardens on Mount Macedon. The cast was included in the company's exhibits at the 1880 Melbourne International Exhibition.Image: B. ThomasSource: B. Thomas
Huntsman and Dogs, also known as Hunter and Hounds or by its French title, Le chaussuer et les chiens, was originally produced by the noted French sculptor, Henri Alfred Marie Jacquemart (1824-96), often known as Alfred Jacquemart, famed for his realistic representations of animal figures. He studied painting and sculpture at the Ecole des Beaux Arts in Paris and was a regular exhibitor at the Paris Salon from 1847. His reputation as one of France's leading monumental sculptors was recognised in 1870 when he was awarded the Chevalier of the Legion of Honour, the country's highest decoration.
Among his many monumental works, Jacquemart also produced a number of sculptures for commercial production, which were cast by the French foundries of Val d'Osne in 'imitation bronze'; a technique of casting in iron that was then coated with a thin surface of copper through electrolysis. Over time, the aging copper developed a green patina giving the appearance of a genuine bronze casting.
Detail of the base of Huntsman and Dogs.
Image: B. ThomasSource: B. Thomas
Val d'Osne exhibited Huntsman and Dogs at the 1879 Sydney International Exhibition and the following year at the 1880 Melbourne International Exhibition where it was mounted on a stone plinth at the front of the eastern forecourt to the Exhibition Buildings, at the edge of Nicholson Street. Val d'Osne was awarded a silver First Order of Merit for their castings at the 1880 Melbourne International Exhibition.
Val d'Osne's display of decorative castings in the eastern forecourt of the Exhibition Buildings during the 1880 Melbourne International Exhibition, with Jacquemart's Huntsman and Dogs in the foreground of the Nicholson Street entrance.
Source: Museum Victoria
One cast of Huntsman and Dogs was purchased by the New South Wales government at the conclusion of the Melbourne Exhibition in 1881 for £180; almost $13,000 in today's terms. It was mounted in the gardens surrounding Sydney's exhibition building, the Garden Palace, but was damaged when the Palace burnt down in 1882. It was restored in September 2001 and is now situated in Sydney's Royal Botanic Gardens.
The Huntsman and Dogs in the Forest Glade gardens apparently remained installed at the Exhibition Building, but – much like its Sydney counterpart – was badly damaged when the Aquarium situated in the building's eastern annexe was destroyed in a fire in 1953. Forest Glade's present owners recount that the sculpture languished for a time at the back of a nursery, until being bought from a Richmond-based art auctioneer after the 1983 Ash Wednesday bushfires. It now finds a fitting home, nestled amongst its garden bed of maples, greeting visitors to these wonderful gardens.
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May 17, 2005
FOS11 Statement in Support ofMarkey-Shays Cargo Security Amendment
Families of September 11 (FOS11) stands in strong support of the Markey-Shays cargo security amendment requiring screening of all cargo on passenger airplanes. Almost four years after 19 men hijacked four planes and murdered 3,000 of our nation's citizens and more than 16 years after a bomb exploded on Pan Am 103, killing hundreds, our country's aviation passengers are left perilously unprotected by the lack of screening of material in airplane cargo holds.
Our state of aviation security is incomplete without including mandatory cargo screening for passenger planes. No passenger can feel safe without knowing that all baggage and cargo has been screened for explosives and dangerous materials, just as each passenger and hand luggage must be screened before boarding. In a time when we are constantly warned of looming threats against our safety, it would be negligent not to take the necessary precautions to make flying in our nation as safe as it can be.
Families of September 11 urges immediate passage of the Markey-Shays cargo security amendment as part of H.R. 1817, the Homeland Security Authorization bill for FY06.
How to Contact Your Elected Officialshttp://www.familiesofseptember11.org/resources.aspx?s=11#439


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If you lose track of how long that food has been in the refrigerator, always remember: If in doubt—throw it out!
For best storage, it's wise to put hot leftovers into shallow dishes or smaller portions to cool quickly. Wait until steam has stopped rising from food before putting it into the refrigerator so that you don't heat up your refrigerator.
Remember to choose strong food-storage containers that are clean and in good condition. And opt for covered containers—they're always a better choice than uncovered bowls or opened cans.
In addition, it's always important to get the food in the refrigerator within 2 hours after it's cooked, or sooner if it's cooled enough. If food has been left out for longer than 2 hours, don't put it back in the refrigerator, and don't keep it for later. It's not safe to eat.
Still not sure? Keep this chart in a handy place. It should give you many of the answers you need to determine how long food can safely be refrigerated.
The following foods will keep only 1 to 2 days in the refrigerator:
These foods will keep 3 to 4 days in the refrigerator:
The following will keep 3 to 5 days in the refrigerator:
The following foods have longer refrigerator-storage times as indicated:


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'The fans, some loaded up with beer and nachos, were in the mood for fun. Every ooh and aah, even for an insignificant play, was amplified given the size of the crowd. Yet the feel in the stadium was surprisingly intimate and the play was easy to follow from the nosebleeds.'
Crosby puts on a show in the snow for record crowd
January 2, 2008 Submitted by
Via: Toronto Star


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42 U.S. Code § 10605 - Establishment of Office for Victims of Crime
There is established within the Department of Justice an Office for Victims of Crime (hereinafter in this chapter referred to as the "Office").
The Office shall be headed by a Director (referred to in this chapter as the "Director"), who shall be appointed by the President. The Director shall report to the Attorney General through the Assistant Attorney General for the Office of Justice Programs and shall have final authority for all grants, cooperative agreements, and contracts awarded by the Office. The Director shall not engage in any employment other than that of serving as the Director, nor shall the Director hold any office in, or act in any capacity for, any organization, agency, or institution with which the Office makes any contract or other agreement under this chapter.[1]
[1] See References in Text note below.
This chapter, the last place it appears in subsec. (b), was in the original "this part", which has been translated as reading in the original "this chapter" meaning chapter XIV of title II of Pub. L. 98–473 to reflect the probable intent of Congress because chapter XIV of title II of Pub. L. 98–473 which comprises this chapter, does not contain parts.
2012—Subsec. (b). Pub. L. 112–166 struck out ", by and with the advice and consent of the Senate" before period at end of first sentence.
Amendment by Pub. L. 112–166 effective 60 days after Aug. 10, 2012, and applicable to appointments made on and after that effective date, including any nomination pending in the Senate on that date, see section 6(a) of Pub. L. 112–166, set out as a note under section 113 of Title 6, Domestic Security.
Section not applicable with respect to a State compensation program that was an eligible State crime victim compensation program on Nov. 18, 1988, until Oct. 1, 1991, see section 7129 of Pub. L. 100–690, as amended, set out as an Effective Date of 1988 Amendment note under section 10601 of this title.
LII has no control over and does not endorse any external Internet site that contains links to or references LII.


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Valentino Spring 2014 Couture
Really, how good are Maria Grazia Chiuri and Pierpaolo Piccioli In their time at Valentino, these cheerful, experienced, sensitive Romans have won over the cognoscenti and the crowd; thrilled the very young, and cracked the cynicism of hard-to-impress grown-ups. That, in a nutshell, is what they demonstrated once again for spring couture, in a show which pushed the parameters of their collection to include both frothy tulle ballerina dresses and impeccably stark, almost colorless columns. "My conversation is with all kinds of women," said Chiuri. "I'm not just interested in dressing myself. We respect and love all kinds of individuality."
Curiously, it feels like going off on the wrong track to go too deeply into their "inspiration." Suffice it to say, theater production and set design have been in their heads since they started going to the opera in Rome. (They've lived in the city all their lives and had never been there until recently; a syndrome all capital-city-dwellers will recognize in themselves.) They got involved with the scenery painters. "What they are doing has been going on since the fourteenth century," said Piccioli. "The artisanal tradition strongly relates to the basis of what we do in couture." Allora: The pathways the models trod on in Paris were hand-painted canvases by the man who does the theater sets in Rome. Somehow, the designers were absorbing the theatrics, but kudos to them: It didn't end up as a literal excursion around a tourist spot.
Yet, if we switch the dialogue to what is relevant to fashion, Chiuri and Piccioli are playing on another plane. On the critical prove-yourself level, the Valentino pair have been challenged to demonstrate that they've got more up their sleeves than long, covered-up dresses in lace—the resonating emotional innovation which first swiveled fashion's eyes in their direction. With this show, they dared to demonstrate that they can go beyond that captivating silhouette, continue with magical embroidery (a whole Garden of Eden scene on a skirt), and make short dresses which have as much innocent romanticism as their long ones. Still, far more intriguing is the other thing: the contrasting elegance of the completely undecorated, amazingly cut columns. Walk one of those into a room, and you are going to stand apart as surely as Valentino's young followers stood apart from bodycon dressers three years ago. We'll see if this new idea has as much impact, but let's note this down here: If it does, these designers thought of it first.


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Constituent Update - Special Alert, January 7, 2014
The U.S.-Canada Regulatory Cooperation Council (RCC) will hold a webinar to update stakeholders on RCC progress on meat equivalence, export certification and nomenclature projects. The webinar is scheduled for Jan. 9, 2014, from 2-4 p.m., ET. Details on joining the webinar can be found at http://actionplan.gc.ca/en/page/rcc-ccr/how-participate-rcc-webinars.
The webinar is designed to review progress on implementation of the equivalence, certification, and nomenclature RCC initiatives and seek input on the next phase of regulatory cooperation in these areas.
A copy of the RCC Action Plan, individual sector work plans, including the meat-related projects, as well as other RCC related information is available at www.trade.gov/rcc/.
FSIS and USDA-related questions, comments and concerns relative to the RCC initiatives and the stakeholder webinar can also be addressed to email@example.com.
For those unable to attend the January 9 webinar, comments for FSIS and other USDA agencies may be directed to this same address for review.


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Wiest: Greeley has a lot to build on
April 5, 2013
As a Greeley native, it is somewhat disconcerting to me that the Greeley Metropolitan Statistical Area's per capita income has fallen from or near the top of the state in the 1970s to the bottom today. Why has that happened, and what can we do to turn this around?
Given Greeley is the largest city in that statistical area, which is essentially Weld County, it seems important to look at what has happened in Greeley. Being on the inside of Greeley's government process for 35 years, and now looking at it from the outside, I would offer the following comments.
I have heard since I left the city in 2005 a variety of reasons why Greeley is on the decline. They range from odor, gangs, schools, transportation and lack of jobs. Let me give you my take on each of these.
Odor to me is a non-issue. In the 1970s, when the Greeley area was near the top of the charts, we not only had the packing plant, but two very large feedlots on our boundaries and a sewer plant that caused problems for east Greeley residents.
The odor-scrubbing technology at the packing plant has been improved dramatically and, of course, the feedlots have been removed. The city sewer plant has received awards for its operational improvements over the years and the complaints from that area have diminished. Being born in Greeley, the odor to me was never an issue and shouldn't be an issue to anyone now.
Yes, Greeley has gangs, but so do most of the cities that are now ranked ahead of us on the per capita income rankings. Greeley police have done a fine job in policing the local gangs to the point where Fort Collins was complaining that Greeley was driving them over there. This may be an issue to some, but it does not seem to me that it is significantly worse than other communities.
I hear that many people have moved to neighboring communities so their children can attend school with higher test scores.
I personally can't believe that the teachers in our district are less dedicated and less competent than in other districts. I know several educators in our system and believe they are outstanding in what they do. The test scores are lower, and perhaps that is a failing in our own family values, in stressing to the children the importance of education and learning.
In today's more mobile world, compared to the '70s, it is much easier for the higher-paid employees to commute to and from Greeley.
Laptop computers and smartphones allow employees to live further away from their employment, and of course, it's the mid-level managers and higher-ups who need to be connected to their operations.
I am assuming that if everyone who earned a living in Greeley would live in Greeley, our per capita ranking would be higher.
Greeley also is one of the largest cities in the state without direct access to an interstate.
Does this lead people to live closer to the interstate to get to Denver and other out-of-town attractions?
Greeley has a lot to be proud of and to celebrate. Fortune 500 companies, world headquarters, a fine university, a diversity of jobs, and quality arts and recreation programs.
There are a lot of cities in this country our size that would love to have what we have.
It may be impossible to change some perceptions of Weld County. Officials have been working to change them forever. Perhaps we just need to recognize and celebrate what we have and build from there.
Leonard Wiest is a former Greeley city manager.
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'Rookie left winger Thomas Vanek, the fifth overall pick in the 2002 draft, says he'll survive without an immediate taste of the NHL. "I knew if there was a lockout, I would develop here," Vanek said. "It's disappointing but it's something I can't worry about. I won't let it get in my head."'
The Sabres Report - September 29, 2004


text: Glory hit London for their fifth show and boy did it deliver! At the ExCel Arena in the heart of Londons Docklands area, the premier Kickboxing promotion in the world went down! In the main event, Remy Bonjasky took on Tyrone Sprong in what turned out to be a thrilling encounter!


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Milwaukee Event Calendar
How the World Began
Feb. 6, 2013 at Stiemke Studio
Religion and science collide in a visceral examination of the way in which we navigate interpersonal relationships involving seemingly irreconcilable beliefs—and just how hard it is to truly listen to one another in an increasingly polarized world.
Looking to rebuild her fractured life, high school biology teacher Susan relocates from New York City to a small Kansas town reeling in the aftermath of a devastating tornado. Ready for more than a little culture shock, Susan finds herself unprepared for the firestorm that engulfs the town after she makes an off-hand comment about the origin of the universe.Milwaukee Repertory Theater


text: OverviewBack to top MRI: Medical Research Institute - Black Powder Pre Workout Bullet Pack Orange Burst - 20 Packet(s) Item# :76308UPC# :633012640126 Brand:MRI: Medical Research Institute Size/Form:20 Packet(s) Ship Weight:2.50 Servings:20 Dosage:1 Packet(s) Flavor:Orange Burst Click here to read a PDF brochure on this product MRI: Medical Research Institute - Black Powder Pre Workout Bullet Pack Orange Burst - 20 Packet(s) MRI Black Powder Instant Release Pre Training Formula Fruit Explosion is a convergence of Medical Research Institute patented technologies, delivered in a rapid absorption pre-workout formula. MRI Performance Black Powder will get you amped, quickly. But there are a lot of products that stimulate your central nervous system (like a cup of coffee). MRI Black Powder Instant Release Pre Training Formula Fruit Explosion goes way beyond that. It is the most complete pre-workout formula ever conceived, spiked with ACTINOS2 IR. Here's what to expect: It literally takes a few moments for Black Powder to get absorbed and get to work. Take it no more than 30 minutes before your workout. You can actually take it right before you walk into the gym and start your first set!The First 30 Minutes in the GymWarm up set? Sure go ahead. Because its good for you. But you are ready to pounce without it. Black Powder's neuromodulators (caffeine, betaine anhydrous, green tea extract) and ACTINOS2 IR get you supercharged from the get go. Mood elevated. Not manic. But steady and strong. Don't worry, the neuromodulation is balanced. No jitters, and ABSOLUTELY no blood glucose concerns. The Insulin Sensitizer Blend ensures excellent cell-balance of glycogen and aminos so you're primed and fueled.Next, you'll immediately notice that you recover rapidly between sets. That's the nitric oxide and creatine talking! Increased blood flow and nutrient delivery to you muscles give you the green light to attack the next set. ACTINOS2 IR's bombards your muscle cells with adaptive response signals that engage every fiber you have. It's go time!You're workout is well under way. And at a pace and intensity level that you've never experienced. Keep going! The Second HalfBetween set recoveries are still there. And you're still amped. Sure, fatigue sets in on each set, but you're taking it to failure and beyond. You see, Black Powder is formulated with beta alanine, potassium bicarbonate, and sodium bicarbonate for muscle stamina and endurance. Lactic acid build up is a thing of the past. Plus the sodium and potassium you lost/metabolized in the first 30 minutes is still in ample supply.And you feel strong. The muscle fiber has plenty of creatine at its disposal for power output and increased load capacity, with plenty of phosphates to feed your body's continual recycling of ATP. Plus you still have tons of energy (ACTINOS2 IR)! Black Powder is loaded with B vitamins and raw muscle fuel like MCTs and malic acid so your energy metabolism remains efficient and steady throughout even the toughest parts of your workout.RecoveryNo more walking off the gym floor like you just got hit by a bus. You're pumped, and your body is in balance. The arginine blend and the rapid absorption ester creatine take the lead in the repair process, and do it RAPIDLY. Physically fatigued? Sure. But not depleted. And you still have the ability to focus. You have what you need to keep going, and do it all over again. Thanks to Black Powder and ACTINOS2 IR.The Awe-Inspiring Black Powder Training EffectYou enter the gym. You dow:" ":ts seem lighter than they actually are. They are not! You attack your sets with a ferocious intensity. It never lets up. The "initial" move of your lifts seems effortless. It is. And that's just what you can feel. There's more.It feels like your muscles recover before you even leave the gym. They do. It seems like muscle growth signals are rapidly pulsing through your body, starting from your first set. They are. You finally know what it's like to fire on all cylinders. The effect is simply devastating to your competition! Now here's the best part. As you step out of the gym, you'll have the throbbing, super-engorged, skin-ripped body as proof of what just transpired! Get used to it. It's all part of the awe-inspiring Black Powder Training Effect!The Key is New ACTINOS2 IR Technology You Get 950% More N.O. in an Instant Blast Until now, MRI speculated supplements have only been hitting a fraction of the muscle's performance targets. But our working hypothesis says that Black Powder has the ability to "light up" metabolic targets previously dormant. That's the best explanation of the performance-enhancing, size-generating, intensity-provoking "cellular explosion" Black Powder has suddenly created.What's causing Black Powder's intense "cellular explosion?" Simply put, the "collision" of two metabolic forces. Both driven by MRI's new ACTINOS2 IR technology. You see, ACTINOS2 IR creates an "instant blast" of nitric oxide, creating levels 950% greater than previously possible. In a nano-second, blood channels "hyper-dilate" - driving Black Powder's precision-calibrated nutrient matrix to your muscle cells in "volumes" never before known. At the same time, the spike of 950% more nitric oxide amplifies "cell-signaling" to levels never before witnessed.This magnifies the signals that control both muscle performance and muscle size! The collision of these two metabolic events seems to be "lighting up" metabolic "targets" previously out of reach through supplementation. And the effect on your training is simply mind-boggling! The Science: Driving Performance and Size to New LevelsScientifically, nitric oxide forms the basis from both performance and size. Nitric Oxide dilates the blood channels that deliver vital training and recovery nutrients to your muscle cells. In addition, nitric oxide signals and regulates muscle growth, muscle contraction, and metabolic adaptation to training. Until now, nitric oxide had a "pre-set" limit. Not any longer. Thanks to MRI's innovative ACTINOS2 IR, Black Powder creates an immediate surge in nitric oxide levels, 950% higher than previously attainable. In an instant, Black Powder's performance/size nutrient complex floods your muscle cells in volumes we never believed possible. Your body's performance and growth signals amplify in intensity, starting at your first set! Your strength, intensity, and focus hit levels they've never known. Your recovery starts before you even leave the gym. That's why with Black Powder, you'll get the most outrageously intense workout of your life, and you'll have the super-dilated skin-ripping pumps to prove it! About MRIMedical Research Institute (MRI) was founded in 1997 to develop nutraceuticals that combine novel active ingredients with cutting edge delivery technology so as to create the safest and most advanced performance products on the planet. MRI continues to push the limits of nutraceutical technology by providing exciting technology advancements in a growing number of product categories. Their products only make it to the shelf if they have been shown to help alter human metabolism and affect positive transformations in body composition and athletic performance. Most importantly, all MRI products are in keeping with their industry leading standards for quality and safety. Products are manufactured at audited facilities that adhere to the FDA's Good Manufacturing Practices guidelines. All products pass tests for ingredient purity and integrity. They have relationships with NSF and the Banned Substances Control Group, non-profit agencies that test random lots of certain products and/or certify their manufacturing facilities.


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You are here
Position Statement 12: Evidence-Based Healthcare
Mental Health America (MHA) is dedicated to accelerating the application of scientific and practical knowledge to help in the recovery of people with mental health and substance use conditions. This focus on evidence-based healthcare spans the development, exposition, evaluation, replication, translation, dissemination and implementation of knowledge about mental health and substance use disorders and their treatment and includes all forms of knowledge, from randomized clinical trials through clinical practice and consumer insights. This process follows up on clinical studies with Patient Centered Outcomes Research (further described below), which compares different interventions to prevent, diagnose, treat and monitor health conditions focusing on the comparative effectiveness of the intervention or service in diverse real-life settings.
Effective access to reliable evidence is vital to the development of an informed decision-making partnership between consumers and providers. Evidence-based healthcare should balance scientific knowledge, clinical expertise and experience, and consumer and family experience and values to inform healthcare delivery and decision-making. To ensure this balance, processes for evaluating and translating relevant evidence in a form accessible to consumers, families, and the general public and for applying such findings to practice and policy should be transparent and driven by consumer and family perspectives and values. This will take work, and MHA pledges to aid in translating and disseminating the needed information and to seek partnerships to that end.(1)
Promising practices. At the crux of the controversy about the application of evidence-based practices is the concern that policymakers and insurance administrators may use lack of expensive randomized clinical trial evidence as a rationale for denying reimbursement for desirable services in order to contain cost. Such policies risk stifling the growth and use of effective "best," "emerging" or "promising" (hereinafter "promising") practices, particularly peer-to-peer services. Of particular concern to consumers and families is that many of the current evidence-based practices cited in this position statement reflect the approaches of earlier eras, and focusing on these practices to the exclusion of others could impede further innovation - particularly for peer-delivered services that lack the profit potential to make randomized trials economically feasible.
While cost is an inevitable consideration in reimbursement decisions, it is of paramount importance to honor consumer needs for expedited access to other treatments when evidence-based treatments are not tolerated or prove ineffective or insufficient. In addition, MHA favors subsidizing and encouraging research into promising but not yet proven treatments. MHA urges that all manufacturers' and patent owners' experimental evidence be fully disclosed to consumers to make that access fully informed. This is of greatest importance with promising practices that are not yet established as evidence-based. As with all other treatment decisions, potential harms must be weighed against potential benefits in the decision to use or forego promising practices. Additional care is appropriate when potential harms are not yet fully established.
MHA supports efforts like the National Registry of Evidence-Based Programs and Practices (NREPP) to create a centralized clearinghouse for evidenced-based practices with transparent criteria for evaluating and approving such practices. It is vital that such a clearinghouse use flexible criteria for what constitutes acceptable evidence, including randomized clinical trials, quasi-experimental studies and observational studies. It is also vital that the evaluation criteria be driven by the goal of recovery for persons affected by mental illnesses and addictions.
Patient Centered Outcomes Research. Traditional academic research regards randomized controlled trials as the gold standard for making causal inferences. Randomized controlled trials are valuable and appropriate in getting to firm scientific conclusions about effectiveness and safety, but we must employ a broader range of methods if we are to address the range of challenges encountered in treating mental health and substance use conditions. Other methods, like open-label trials (in which both the researchers and participants know which treatment is being administered, such as studies of peer services and exercise), observational and quasi-experimental methods can be used to study more clinically relevant interventions and populations and measure more consumer-relevant outcomes, using diverse populations of study participants from a variety of practice settings.(2)
Of greatest importance, investments must be made in longitudinal research that demonstrates the effectiveness of treatments in real-world settings that account for the breadth of experience and the diversity of the larger population. This is the ultimate level of evidentiary support, referred to in this policy (and in the federal Affordable Care Act) as Patient Centered Outcomes Research. To that end, consumer and family input and involvement should drive both research design and evaluation so that the evolving evidence base represents the values, goals and priority health outcomes they seek. Then, research findings should be published in lay language so that consumers and families can understand and use the information in their healthcare decision-making.(3)
Cultural and linguistic competency is an essential element of evidence-based healthcare. The unique cultural perspectives and outcomes relevant to diverse populations need to be incorporated at all levels of evidence development and implementation.
The boundaries of scientific research are constantly being stretched, revealing new understandings and options for treating many chronic illnesses, including mental health and substance use disorders. Yet even as emerging science gives us information about how and why mental illnesses and addictions affect individuals, and about genetic biomarkers that may better guide treatment choices, it also reveals the absence of universally effective treatments and practices. Newer studies often erode old findings, due in part to the bias toward publication of positive results and in part to the absence of full disclosure.(4) The result is that negative findings show up after an intervention or service has come into common practice. In particular, pharmaceutical use by the general population commonly reveals side effects that were not adequately evaluated in the preapproval clinical trials.
In addition, the Institute of Medicine estimates that it takes nearly two decades for new knowledge to translate into effective practice and policy that can influence treatment choices for an individual.(5)
Prominent reports from the Surgeon General,(6) the President's New Freedom Commission on Mental Health(7) and the Institute of Medicine(8) all underscore the importance of narrowing the gap between research and implementation of evidence-based practices. Consequently, government agencies, private-sector health plans, academic research centers and other stakeholders are dedicating enormous resources to evaluating current science and practice, disseminating information about promising practices, and guiding the implementation and replication of such evidence-based approaches to healthcare.(9)
Patient Centered Outcomes Research and PCORI. The 2010 Affordable Care Act authorized the development of an independent, non-profit organization to drive the development, synthesis and use of research. The Patient Centered Outcomes Research Institute (PCORI) is governed by a 21-member Board of Governors, and is tasked with helping patients, clinicians, purchasers and policy makers make better informed health care decisions. PCORI will commission research that is responsive to the values and interests of patients and will provide patients and their caregivers with reliable, evidence-based information for the health care choices they face.(10)
Evidence-based Practices
SAMHSA, the Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services, has undertaken to recognize evidence-based practices(11) and to translate some of them into toolkits for consumers, families and the general public. As of 2011, SAMHSA has, through various means, recognized eleven practices as evidence-based and one practice as promising for the treatment of mental health and substance use conditions,(12) has written toolkits ("KITs," based on "Knowledge Informing Transformation") describing seven of them,13) and is preparing an additional five toolkits,(14) as detailed below:
- Assertive Community Treatment (ACT or PACT) refers to a means to provide a full-range of services within a community setting to people who have severe mental illnesses such as schizophrenia, bipolar, depression or schizo-affective disorder. The primary goal of this treatment is to prevent hospitalization by assuring regular therapeutic contact and regular use of medication. A multi-disciplinary team provides assistance in a number of areas including daily activities, family life, health, medication support, housing assistance, financial management, entitlements, substance abuse treatment and counseling. The key to its success is a high staff to consumer ratio (at least one to 10 consumers), provision of services where they are needed (in the community), uninterrupted care as someone from the team is always available, and time-unlimited support. A SAMHSA toolkit has been developed for this practice.(15)
- Supported Employment is a program that aids consumers in finding competitive jobs (defined as at least minimum wage jobs open to the general public) that are well suited to their interests and abilities. Supported employment is based upon six principles which include: (1) eligibility is based on consumer choice (no one is excluded), (2) employment is integrated with treatment for continuity, (3) competitive employment is the goal, (4) job search starts soon after a consumer expresses interest in working (there are no prerequisites such as training classes or intermediate work experience), (5) follow-along supports are continuous, and (6) consumer preferences are important. Employment specialists work alongside consumers to ensure that these six principles are met. A SAMHSA toolkit has been developed for this practice.(16)
- Integrated Treatment for Co-occurring Disorders is a treatment model in which the same treatment team provides both mental health and substance abuse treatment for those with "dual disorders" (simultaneously occurring substance abuse and mental illness). Integrated treatment improves chances for meaningful recovery. Within this model, consumers receive case management, outreach and other much-needed services such as housing and supported employment. Counseling services are tailored to those who have dual disorders and include assessment, motivational treatment and substance abuse counseling. Family members are also educated about the mental illness and substance abuse, and are given support as well. Those with dual disorders are in a high-risk group and vulnerable to a host of corollary problems such as relapse, troubled finances, homelessness and health crises, which is why integrated treatment is so critical to successful outcomes.(17) A SAMHSA toolkit has been developed for this practice.(18)
- Family Psychoeducation is a practice that forges partnerships between families, consumers and practitioners, who come together to support recovery. Families are given information about mental health and substance use conditions and develop coping skills. This practice has several phases. (1) The first phase involves family members in introductory sessions where they meet with a practitioner and explore the warning signs of illness, the family's reactions to symptoms and behaviors, and feeling of loss and grief, and set goals for the future. (2) The second phase is an educational workshop in which families come together to learn about the microbiology of the illness, normal reactions, managing stress and safety measures. (3) The final component is problem-solving sessions in which the consumer and families meet every two weeks for the first few months to learn to deal with problems in a pragmatic, structured way. A SAMHSA toolkit has been developed for this practice.(19)
- Illness Management and Recovery (IMR) is a psychiatric rehabilitative evidence-based practice that is designed to empower people who have serious mental illnesses to understand and manage their illness effectively. During a series of weekly sessions, mental health practitioners aid consumers in developing their own tailored strategies for coping with their illness, constructing their own goals for recovery and playing an integral role in decision-making about their treatment. Nine topic areas are covered in the program: (1) teaching recovery strategies, (2) practical facts about mental illness, (3) the stress-vulnerability model and treatment strategies, (4) building social support, (5) reducing relapses, (6) using medications effectively, (7) coping with stress, (8) coping with problems and symptoms, and (9) getting your needs met in the mental health system. Practitioners use a variety of techniques to accomplish these goals, such as cognitive-behavioral, educational and motivational strategies. A SAMHSA toolkit has been developed for this practice.(20)
- Permanent Supportive Housing is a program to provide housing distinct from social supports for people with mental health and substance use disorders. A SAMHSA toolkit has been developed for this practice,(21) which defines Permanently Supportive Housing as follows: (1) Tenants have a lease [or sublease] in their name, and, therefore, they have full rights of tenancy under landlord-tenant law, including control over their living space and protection against eviction. (2) Leases do not have any provisions that would not be found in leases held by someone who does not have a psychiatric disability. (3) In particular, participation in services is voluntary and tenants cannot be evicted for rejecting services. Although Permanent Supportive Housing is designed for people who need support services, person's Permanent Supportive Housing home is just that, not a treatment setting, as has been common in many residential facilities operated by mental health systems. (4) House rules, if any, are similar to those found in housing for people who do not have psychiatric disabilities and do not restrict visitors or otherwise interfere with a life in the community. (5) Housing is not time-limited, and the lease is renewable at tenants' and owners' option until abandonment or eviction. (6) Before moving into Permanent Supportive Housing, tenants are asked about their housing preferences and are offered the same range of choices as are available to others at their income level in the same housing market. As stated in (3) above, tenants have choices in the support services that they receive. (7) Housing is affordable, with tenants paying no more than 30 percent of their income toward rent and utilities, with the balance available for discretionary spending. (8) Housing is integrated. Tenants have the opportunity to interact with neighbors who do not have psychiatric disabilities. (9) As stated in (3) above, tenants have choices in the support services that they receive. They are asked about their choices and can choose from a range of services, and different tenants receive different types of services based on their needs and preferences (10) As needs change over time, tenants can receive more intensive or less intensive support services without losing their homes. This flexibility stands in sharp contrast to the residential treatment programs and transitional housing traditionally offered by mental health systems. (11) The support services that are provided promote recovery and are designed to help tenants choose, get, and keep their housing. (12) The provision of housing and the provision of support services are distinct. In residential treatment programs, staff often provides support services and handles housing functions such as the application, move-in, rent collection, rule enforcement, and eviction. In Permanent Supportive Housing, housing and support services are handled separately to avoid all possibility of coercion.
- Medication Treatment, Evaluation and Management (MedTEAM) refers to systematic use of medications. Medication Treatment, Evaluation and Management is an evidence-based approach for offering medication management to people with serious mental illnesses. Four factors are involved in providing evidence-based medication management: (1) people who prescribe medications (prescribers) must know the best current evidence from systematic research; (2) they must integrate that information with their own clinical expertise; (3) prescribers must be aware of consumers' experience and be able to integrate that experience into medication decisions; and (4) medication management should be based on active consumer participation, mutual communication, and shared decisionmaking. A SAMHSA toolkit has been developed for this practice.(22)
- Consumer-operated Services are endorsed by SAMHSA, but the evidence base is still weak. SAMHSA is developing a toolkit based on the currently available evidence. However, consumer-operated services are very broad in their missions, and the toolkit will not cover all of them. More study will be required to validate other promising peer-to-peer programs.
- Treatment of Depression in Older Adults requires different interventions than those used for younger people. MHA has identified a dearth of documented evidence-based practices that are helpful in addressing mental health and substance use problems of older people. The one exception is the use of community-based, multidisciplinary mobile geriatric teams.(23) SAMHSA is developing a toolkit for this practice, but its breadth is unknown.
- Interventions for Disruptive Behavior Disorders in Children are needed in both school and home settings. Although MHA has endorsed School-wide Positive Behavior Support in Schools (SWPBS),(24) the breadth of the evidence-based practices supported by SAMHSA for disruptive behavior disorders is unknown. SWPBS is based on the assumption that when faculty and staff in a school actively teach and acknowledge expected behavior, the proportion of students with serious behavior problems will be reduced and the school's overall climate will improve. Strategies such as behavioral coaching, behavioral rehearsal and role play, daily goal setting, and self-monitoring can be helpful in teaching students to manage their own behavior and emotions more effectively. SAMHSA is developing a toolkit for this practice.
- Mental Health Promotion has been shown to increase social connectedness. It builds social capital, promotes community well-being, overcomes social isolation, increases social connectedness and addresses social exclusion. Evidence-based practices include:
(1) community building and regeneration programs, (2) school-based programs for mental health and well-being, (3) structured opportunities for civic participation, (4) workplace mental health promotion, (5) social support, such as home-visiting and parenting programs, (6) volunteering, (7) community arts programs, (8) physical activity/exercise, and (9) Media and social marketing campaigns that challenge stigma.(25) SAMHSA is developing a toolkit for this practice.
- Supported Education has emerged as promising practice in psychosocial rehabilitation for consumers with serious mental illnesses, but proven evidence-based practices for supported education models are very limited. Supported education programs and research have not been subjected to the rigorous, consistent and repeated methodology of supported employment. However, effective outcomes and significant findings in program attendance, enrollment in postsecondary education, self-esteem, peer support and reduced healthcare costs make supported education a promising practice for the treatment and rehabilitation of adults with serious mental illness.(26) SAMHSA is developing a toolkit for this practice but will refer to it as a promising practice rather than as an evidence-based practice.
Opportunities & Challenges
A stronger focus on evidence presents an opportunity to improve the quality of mental health and substance use disorder care, empower consumers and families to seek and demand continually improving care and services and ensure consistently better and more meaningful outcomes for consumers and families. In addition, there is an opportunity to redeploy resources to more outcome-driven programs and practices and to incorporate the recovery paradigm into the services and supports that consumers and families receive.
There are several challenges to the effective realization of evidence-based healthcare.
As the private and public markets rush to embrace anything labeled "evidence-based," one concern is that policymakers and administrators will inappropriately use evidence-based findings as a cost containment tool and, in the process, fail to respond to consumer needs and stifle the growth of new technologies, therapies and practices. Of highest concern is the potential that reliance on narrowly defined evidence-based practices to the exclusion of promising treatments or programs will preclude the development of a rigorous evidence base for a broader range of options.
Need for recovery focus. Consumers and families are particularly concerned that many evidence-based practices were developed and evaluated prior to general acceptance of the recovery model embraced by MHA and the consumer movement and therefore have little real-world relevance to consumers' quest for a full life in the community. It should be noted that SAMHSA's announced development of toolkits for consumer-operated programs, supported employment and supportive housing go far to address this concern, and SAMHSA has emphasized the recovery paradigm in the toolkits that it has published. However, the existing research base is ill-fitted to address the values represented by the recovery movement, including individualized care, holistic care and peer support. Clinical research designs -particularly the "gold standard" of large, long-term, randomized, double-blind, active-placebo-controlled trials - often do not effectively measure important outcomes, such as quality of life, employment, relationships, and the real-life impact of side effects and drug interactions. Realities of the individual consumer (age, gender, ethnicity, co-occurring disorders, and treatment goals and preferences) are inventoried, but statistically insignificant numbers usually preclude conclusions specific to subgroups.
Patient Centered Outcomes Research and PCORI. The next essential step in the development of evidence-based treatments for mental health and substance use conditions is the Patient Centered Outcomes Research (also called Comparative Effectiveness Research) that will look at the most important functional outcomes for consumers rather than only the standardized scales documenting reduction of symptoms that are the staple of most academic clinical research. More recent practical trials like the CATIE and STAR*D trials(27) have been designed to improve the collection of such information, refocusing research on effective outcomes in large representative populations in real-life settings, but it will take time to build this more relevant body of evidence. PCORI will assist in facilitating the generation and use of this evidence, focusing on input by consumers and providers. Engagement with PCORI will be a key opportunity to promote the preferences of consumers, as well as providing guidance for better dissemination of research to consumers, providers, payers, and policy makers.
Consumers and families should be recognized as allies of researchers and should be trained to be full members of research teams. PCORI, MHA and other advocates, researchers and governments need to contribute to the translation, summarization, and dissemination of evidence-based information, in simple, lay language, for use by consumers in helping determine their preferred course of treatment. The SAMHSA toolkits recognizing 12 evidence-based or promising practices are a great step in advancing this needed effort, and MHA commends SAMHSA for its efforts. The difficulty to come is the synthesis of additional information that may become unmanageable in scope and the updating that will be required as more patient centered outcome research becomes available.
A related concern is the dearth of research focused on response differences by people of different age, gender, sexual orientation, disability, race and ethnicity, and income. Evaluations of existing scientific evidence by the Agency for Healthcare Research and Quality (AHRQ) and other entities demonstrate the limitations of clinical trials in terms of adequate participation by consumers across age, gender, and racial and ethnic categories. And the lack of focus on subgroups makes it impossible to assess differences in subgroup responses. This may have the unintended consequence of exacerbating health care disparities.
Policy and program barriers to implementation of evidence-based practices in the mental health and substance use disorder care systems are a reality in every community. Such barriers include organizational structure, limitations on financing, unique state regulation and licensing issues, the lack of clear guidelines and models for implementation, workforce shortages and lack of sufficient training resources, technology deficits and resistance to change. It is essential that advocates and consumers champion effective treatments and question ineffective treatments to prevail against the many sources of institutional inertia and to stimulate a successful therapeutic dialogue. This will require a new level of dedication to staying abreast of developments in the scientific literature.
Call to Action
MHA envisions a healthcare system that ensures accessible, high-quality preventive and treatment services for all people regardless of treatment setting, age, gender, sexual orientation, disability, racial or ethnic background, or income. The growing emphasis on evidence development and the determination of evidence-based practices holds the promise of moving the healthcare system toward our vision. But there is a significant danger that over-emphasis on already proven practices may curtail innovation and overlook promising treatment approaches that are on the threshold of being evidence-based. Therefore, it is essential that stakeholders in the mental health and substance use recovery communities become familiar with the proliferation of initiatives that focus on evidence-based healthcare. In addition, advocates, consumers, families, clinicians, and providers should work to identify and promote key questions for future research that are relevant to the most important consumer outcomes and that address differences in age, gender, sexual orientation, disability, race and ethnicity, and income. MHA advocates for the following principles of evidence-based healthcare:
- Transparency. The process to evaluate evidence and develop evidence-based programs, interventions, treatments and policies should be open to the public and include stakeholders in the decision-making process. Consumers and families should have active and meaningful roles on review, evaluation and governing bodies that make decisions about the application of evidence in practice and policy. In addition, clear and complete research findings should be communicated to consumers and families, and tools and practices should be developed to aid consumers in how to use such information in their dialogue with caregivers. MHA and its affiliates should advocate broad dissemination of studies and preparation and dissemination of summaries and translations of clinical research, in order to allow consumers and payers to evaluate all of the data, rather than just those that support the provider (whether direct or indirect), in a user-friendly format.
- Individualized Care. Scientific and practical evidence can aid in determining the best intervention to optimize an individual's care, but such evidence alone cannot guarantee the right choice for every individual. Therefore, it is important that reimbursement and coverage policies reflect the need for individualized care and maintain flexibility to respond to consumer needs and to test promising practices.. In addition, it is important to advocate for wider investment in Patient Centered Outcomes Research, practical clinical trials and other research methods that generate evidence applicable to real-world treatment settings.
- Consumer-relevant Outcomes. The inclusion of consumers and families in the design, discussion and evaluation of clinical trials and other research is also important because consumers can articulate the most relevant variables for their quality of life and health outcomes. Current research is heavily focused on symptom management rather than on quality of life outcomes such as ability to work, independent living and social connectedness. More important, inclusion of people affected by mental illnesses and addictions can ensure that evidence-based healthcare is grounded in the recovery model.(28) Thus, Patient Centered Outcomes Research is essential, PCORI needs to be engaged by consumer advocates to ensure that consumer preferences are applied to its research, and research needs to go beyond RCTs to encompass the realities of diverse real-world settings and diverse groups of consumers.
- Quality First. Safety and individually tailored treatment should be the top goal of an evidence-based healthcare system. Treatment costs are relevant to the discussion but must be weighed in the system context -total burden of disease costs for an individual across services and settings -rather than restricting costs to a particular cost center - like outpatient care. In the context of clinical decision-making, cost should be evaluated by providers and consumers after a careful weighing and discussion of benefits and risks and a dialogue that emphasizes choice across a range of therapeutic options.
- Fidelity. Adherence to program standards and principles is important to ensure reliable outcomes. Ongoing fidelity measurement is especially important in programs or practices that have been altered to suit the age, gender, disability, ethnic or cultural needs and income of those being served. While complete fidelity in implementation may not be possible or desirable, providers need to document the changes being made and rigorously measure the outcomes and the effects of the changes. Policymakers should take fidelity issues into consideration so that the policies are flexible and appropriate.
- Cultural and Linguistic Competence. Mental health and substance use research has too often excluded diverse populations, which has created an even wider gap between research and practice for racial and ethnic minorities.(29) Similar issues arise in the application of research findings to different groups based on age, gender and sexual orientation. Cultural competence must be integrated into all evidence-based practices and at all stages of implementation. Research should be designed and developed by and with input and participation from members of specific cultural and ethnic populations. Practices should be adapted, whenever appropriate, to the cultural and linguistic groups being served. Outcomes of evidence-based practices should be evaluated in terms of culture-specific and culturally relevant outcomes.
Effective Period
This policy was Approved by the Mental Health America Board of Directors on September 17, 2011. It is reviewed as required by the Mental Health America Public Policy Committee.
Expiration: December 31, 2016
- See, e.g., National Association of Mental Health Planning & Advisory Councils, Science to Service: Implementing Evidence-based Mental Health Services. A Guide for Mental Health Planning and Advisory Councils, cited as DHHS Publication. Rockville, Maryland: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (2005). http://www.namhpac.org/PDFs/01/sciencetoservice.pdf . In addition to the practices currently recognized as evidence-based by SAMHSA, NAMHPAC describes four additional practices focused on young people previously endorsed in some form [citation needed] by SAMHSA that are not currently recognized as such by SAMHSA. The NAMHPAC brochure paperwork was returned to the SAMHSA Project Officer in 2006, and the brochure was never officially endorsed by SAMHSA. NAMHPAC posted it to its website in the form presented to the Project Officer. The four semi-recognized practices are:
(1)Therapeutic Foster Care is an evidence-based practice for children and adolescents who have a history of chronic antisocial behavior, delinquency or emotional disturbance. In addition, children and adolescents with complex physical health problems may be placed in therapeutic foster care (also known as multidimensional treatment foster care, treatment-foster family care, and family-based treatment). This type of care is provided as an alternative to hospitalization, incarceration, or different types of group or residential homes. Foster families are carefully trained to provide a structured environment for these children where they can learn social and emotional skills, such as emotional self-awareness, anger management and conflict resolution. Participants stay with these families for several months; in certain programs, participants are separated from their usual peer environment and closely supervised in school, at home, and in the community. One of the ultimate goals is often to reunite the family once functioning is improved, which is often accomplished through psychological therapy for participants and members of their biological families.
(2)Multi-Systemic Therapy (MST) is an evidence-based practice that targets juvenile offenders and views treatment as "occurring across a complex network of interconnected systems that embrace individual, family, and extrafamilial (peers, schools, neighborhoods) factors." Intervention may occur in one or more of these systems. MST uses a variety of treatment techniques, including cognitive and behavioral approaches to treatment. Services are delivered in the community, often in settings such as schools or homes. The technique is intensive in nature, usually requires several hours of intervention per week, and seeks to actively involve the family in treatment. The MST treatment model adopts an individualized set of protective and risk factors in the treatment plan for each child, seeking to identify and minimize risk factors while maximizing protective factors. A variety of pragmatic interventions at the family and systems level that affect these risk and protective factors have been shown through a body of research to be effective in reducing delinquent behavior. MST programs may also help to improve parenting skills at the family level, or may focus on improving communication between parents and teachers.
(3)Positive Behavioral Interventions and Supports (PBIS) is another evidence-based practice being used with children and adolescents, which uses the principles and techniques of behavioral analysis to produce behavioral change. These techniques were initially developed to treat people with severely aggressive or self-injurious behaviors. PBIS has evolved into a behaviorally-based intervention process that can be used to target individuals as well as entire school communities.
(4)Parent-child Interaction Therapy (PCIT) is a type of behavioral treatment for young children. Typically, the treatment involves having a parent interact with their child, while a PCIT-trained therapist in another room whispers instructions for improving communication and interaction with the child into an earphone that the parent wears. Coaching and role playing are also used. The program was designed to improve the behavior of children who have temper tantrums, difficulty in school, challenging authority figures, swearing and defiance.
- Tanenbaum, S. J., "Evidence-based Practice as Mental Health Policy: Three Controversies and a Caveat," Health Affairs, 24:163-173(2005).
- Miller, J. and Thompson, S., Findings of a Focus Group of Consumers on Evidence-based Practices Challenges and Opportunities: Final Report. Unpublished manuscript. National Mental Health Association and NAMI for NASMHPD Research Institute (2004).
- Lehrer, J., "The Truth Wears Off," The New Yorker, December 13, 2010 http://www.newyorker.com/reporting/2010/12/13/101213fa_fact_lehrer
and the author's January 3, 2011 blog response, http://www.newyorker.com/online/blogs/newsdesk/2011/01/jonah-lehrer-more-thoughts-on-the-decline-effect.html
- Institute of Medicine, Committee on Quality of Health Care in America, Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, ISBN 0-309-07280-8, Washington DC (March 2001). http://www.iom.edu/Reports/2001/Crossing-the-Quality-Chasm-A-New-Health-System-for-the-21st-Century.aspx.
- Office of the Surgeon General, Public Health Service, Department of Health and Human Services, Mental Health: A Report of the Surgeon General (1999), www.surgeongeneral.gov.
- The President's New Freedom Commission on Mental Health, Achieving the Promise: Transforming Mental Health Care in America. DHHS publication SMA-03-3832 (2003), http://store.samhsa.gov/product/SMA03-3831.
- Institute of Medicine, Committee on Quality of Health Care in America, Crossing the Quality Chasm: A New Health System for the 21st Century, supra at footnote 5 and Institute of Medicine, Committee on Crossing the Quality Chasm: Adaptation to Mental Health and Addictive Disorders, Board on Health Care Services, Improving the Quality of Health Care for Mental Health and Substance-Abuse Conditions. Washington DC: National Academies Press (2005), http://www.iom.edu/Reports/2005/Improving-the-Quality-of-Health-Care-for-Mental-and-Substance-Use-Conditions-Quality-Chasm-Series.aspx.
- For links to these initiatives, see National Working Group on Evidence-based Healthcare, www.evidencebasedhealthcare.org.
- Patient Centered Outcomes Research Institute, http://pcori.org/.
- Many of these summaries and those in footnote 1 have been condensed from the summaries published in Science to Service, supra, footnote 1, at p. 36-41.
- For SAMHSA publications generally, see http://store.samhsa.gov/facet/Treatment-Prevention-Recovery
- http://store.samhsa.gov/facet/Professional-Research-Topics/term/Evidence-Based-Practices?filterToAdd=Kit
- Blyler, C., "Evidence-based Practice KITs: Moving Science into Practice," power point presentation to the American Association of Community Psychiatrists, October 14-16, 2010. No URL available.
- http://store.samhsa.gov/product/SMA08-4345
- http://store.samhsa.gov/product/SMA08-4365
- Drake, RE, Mueser, KT. Brunette MF, & McHugo, G.J., "A Review of Treatments for People with Severe Mental Illnesses and Co-Occurring Substance Use Disorders," Psychiatric Rehabilitation Journal, 27 (4): 26-374 (2004).See also MHA Position Statement 33, Substance Use, Abuse or Dependence and Co-occurring Interactive Disorders. http://www.nmha.org/go/position-statements/33.
- http://store.samhsa.gov/product/SMA08-4367
- http://store.samhsa.gov/product/SMA09-4423
- http://store.samhsa.gov/product/SMA09-4463
- http://store.samhsa.gov/product/SMA10-4510
- http://store.samhsa.gov/product/SMA10-4549
- Bartels, S.J., Dums, A.R., Oxman, T.E., Schneider, L.S., Areán, P.A., Alexopoulos, G.S., & Jeste, D.V., "Evidence-based Practices in Geriatric Mental Health Care," Psychiatric Services 53(11):1419-1431 (2002). http://psychservices.psychiatryonline.org/cgi/reprint/53/11/1419
- http://www.nmha.org/go/position-statements/45
- Evidence-based Mental Health Promotion Resource, published by the Public Health Group,
Victorian Government Department of Human Services, Melbourne, Victoria (2006).
See also MHA Position Statement 48, Prev


text:
The latest glimmers of post-recessionary good news for the profession come in a new career survey of interns, jointly released by the AIA and the National Council of Architectural Registration Boards (NCARB). Seventy-eight percent of respondents to the online survey, conducted in 2012, reported that they were employed in professional architecture work, up 8 percent from the last time the survey was conducted in 2010. Just 6 percent of respondents stated that they were unemployed, down 11 percent from two years before. And among respondents who were laid off from a position, 68 percent indicated that they were likely to stay in the profession, a slight uptick from the 64 percent who said that they would in the previous survey.
The Rickinson Group, an independent marketing research company, administered the 2012 survey, which had 10,003 eligible respondents from the more than 95,000 invitations that were sent to potential candidates.
Aside from the slightly better economic conditions suggested by the data, the survey also explored the progress and attitudes of interns towards licensure. Thirty-four percent of respondents said they had completed the Intern Development Program (IDP), with another 43 percent saying they are currently participating in the program. Forty percent of respondents said they were taking the Architect Registration Examination (ARE) concurrently with IDP.
The data showed that for some interns, completing the ARE was taking longer than indicated in previous surveys. Thirty-five percent of respondents who had completed the ARE said it took three or more years, up from 31 percent in 2010. And 46 percent of respondents who hadn't yet completed the exams indicated that that they expected it to take more than three years to complete them, a figure up from the 27 percent who said the same in 2010.
Thirty-nine percent of respondents have not taken any divisions of the ARE, and, among that group, 56 percent cited a lack of preparation time and 54 percent cited the cost as reason they have not yet taken the test.
Among interns, the perception of the test's difficulty has risen in the last decade: 66 percent of respondents rated the ARE as difficult (on a scale of "too difficult" to "too easy"), about the same percentage as in 2010 but a significant increase from the 2003 survey, in which 48 percent respondents rated it too difficult. In fact, 20 percent of respondents to the 2012 survey said they had taken some portion of the ARE but had not passed at least one part, an increase of 7 percent from 2010.


text: I'm TRYING to organize things here...there's a ton of great work (thanks to everyone who has contributed) and I'll get it all organized over the next few days, I'll make sure I get all the Wallpapers that you guys have made into this thread with labels for the thumbnails...and I'll create thumbnails for those images that don't have them now. In the future, we'll be setting up a more "user friendly" gallery...which will include step by step Photoshop tips as well...So if you have a technique you use, that you want to share, there'll be a forum to do so. Until then, if you see somthing you like, click on the thumbnail, or right click on the images that don't have a thumbnail and voila, it's yours. Another way to download these pics is to visit Jacs' site http://dallascowboys.tk/ If you've got a new wallpaper, please start a new thread so we're all alerted to that fact that a new wallpaper has been made...I'll include it in the gallery below as well. Keep up the great work, it really adds to the site... Ace of Spades: BrainPaint Hood's: inevadropit: Irvinite Jacs SuperSafety 31 zorg222 Juke: Non Cowboy Stuff: Inevadropit Jacs Juke


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Melissa McCarthy Gossip
Melissa McCarthy gossip, latest news, photos, and video.
The Melissa McCarthy Problem
I've been having something of a Melissa McCarthy problem for the last few months. I loved her as Suki of Stars Hollow, and so was excited to see her elevated to prominence in pop culture by way of Bridesmaids, but ever since that movie, I've experienced the dawning horror of realizing that Melissa McCarthy is overrated. Full Story
Worst Dressed: Melissa McCarthy
Kevork Djansezia/Kevin Winter/Ethan Miller/Michael Buckner/Getty
It pains me to have to say it. But you know that I'm right. I looked at that dress, felt disappointed, and then went back to look at McCarthy's award season to see what I wanted instead. I mean, it's hard to say. All her previous gowns have been a type. A jersey-esque long-sleeve with a v neck in a muted jewel colour. Full Story
Worst SAG Choker: Kristen Wiig
Frazer Harrison/Jason Merritt/Kevin Winter/Getty
I like Kristen Wiig so much but that f-cking choker was so objectionable to me it almost affected how I felt about the wearer, this is what you risk with a terrible accessory. Like, I'm all for understated Balenciaga. And in many ways, Kristen Wiig is very understated Balenciaga. It's the anti-Marchesa. Full Story
GG Worst Bridesmaids: Kristen Wiig and Maya Rudolph
Frazer Harrison/Jason Merritt/Getty
Easy. Retract your claws. Read a few lines and then see if maybe you want to punch me. So there they were, Wiig and Rudolph (and McCarthy, yes, but put a pin in that for one second). Bridesmaids is, if not the biggest movie of the year, certainly the biggest movie story. Right? There's no question. Full Story
Oscar Shaping: SAG nominations & Leo > Fassy
Kevork Djansezian/Getty
Here are the 5 actors nominated for a Screen Actors Guild Award: George Clooney, The DescendantsDemian Bichir, A Better Life Leonardo DiCaprio, J. Edgar Jean Dujardin, The ArtistBrad Pitt, Moneyball Missing?Michael Fassbender. Leonardo DiCaprio, who'd been losing so much momentum, who barely factored in any of the critics' selections, suddenly just. Full Story
Made 'Maid
Melissa McCarthy, coming off a surprise Emmy win—surprising only because that show she's on blows chunks, not because she isn't a talented actress/comedienne—hosted SNL over the weekend. Did you see it? It wasn't horrible. But it wasn't great. It was a long way from great. Sketches tend to drag too long on SNL these days (that "Arlene" sketch was INTERMINABLE and I can't even talk about the Lulu Diamonds bit), and much of McCarthy's innate comic ability was crushed under the weight of too-long scenes and bits ground into the dirt by repetition. Full Story
Worst Winning Dress – Melissa McCarthy
Written by Duana Oy, oy, oy. Again we wonder why we're looking at the dress, rather than the woman. So let me dispense with this part first. I didn't like Melissa McCarthy's dress. I didn't think it was attractive to look at. Full Story


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The regular officials must be loving what they see right now. Total incompetence, confusion and outright terrible calls. They have all the power right now and they know it. I think the league ( and especially the greedy owners ) thought the games would be ok with replacement officials and the integrity of the game wouldn't be lost. They could not have been more wrong. The planning was so poor that the official who made the terrible touchdown call in Monday Night's game was a HIGH SCHOOL official. Not a Division One college ref. High School. The league and owners made their bed. Now they have to lie in it.
As always, home team in CAPS.
BALTIMORE 13 Cleveland
The Ravens are coming off of a big win Sunday Night, and now basically have a bye week. Even with the short week I don't see any issues for Baltimore here.
Ravens 27-10
Seattle 2 1/2 ST. LOUIS
Even though the Seahawks got a gift win Monday Night, they aren't too bad. The Rams are about evenly matched. I would like to think that Seattle has some momentum from Monday's win, but I think the Rams take it here.
Rams 23-21
ARIZONA 6 Miami
The Cardinals are 3-0 for the first time in their history, and they deserve it. I don't know how long it will last, but I think it goes on for at least one more week. I don't think Miami is terrible, but they aren't good either. I'll take Arizona.
Cardinals 24-16
ATLANTA 7 Carolina
The Falcons are a mild surprise at 3-0. They have looked good. I thought Carolina looked pretty decent until last week's pasting at the hands of the Giants. They aren't that bad, but I don't think they are good enough to be a hot Atlanta team right now either.
Falcons 26-17
DENVER 6 1/2 Oakland
This should be a nice bounce back game for the Broncos, who have lost two in a row. The Raiders did win last week, but they aren't much. I think the Broncos win this game, fairly easily.
Broncos 30-14
Cincinnati 2 1/2 JACKSONVILLE
The Bengals have won two in a row, and they could be a dark horse in the AFC. As for the Jaguars, um, no. They will end up being one of the worst teams in the league despite winning last week. I don't think the Bengals win easily, but a cover shouldn't be a problem.
Bengals 26-14
San Francisco 4 NEW YORK JETS
The 49ers got stunned last week, and with the emergence of the Cardinals, they need to get the ball rolling. This one won't be easy, but the Jets did lose Darrell Revis for the year. That is a big loss. Something tells me though that the Jets pull this one out. May be being at home will help.
Jets 20-17
New England 4 BUFFALO
The Patriots are below .500 for the first time in years, and have gotten off to a very disappointing start. Buffalo is 2-1, and they could be interesting down the stretch. I think, though, that the Patriots vent their frustrations this week. I can sense a blow out in Buffalo. If the Patriots lose and fall to 1-3, I think all hell might break lose in New England. To some, I think it already has.
Patriots 38-17
TAMPA BAY 2 1/2 Washington
This is a battle of the mediocres, and I think Tampa has the better team. I had a feeling that the Redskins would slip, but it is a long season. I'll take the Buccaneers at home.
Bucs 21-16
KANSAS CITY 1 San Diego
The Chiefs finally won last week, and may be they will finally go on a run. The Chargers are no longer undefeated, but I don't think they were that good anyway. Winning here could propel the Chiefs a little bit. San Diego doesn't impress me. I'll take the Chiefs.
Chiefs 27-24
HOUSTON 12 Tennessee
The Texans passed their first big test last week, so they can't afford a let down against an inferior team. Right now they are the class of the AFC. I don't think the Titans get in their way this week.
Texans 29-14
DETROIT 4 1/2 Minnesota
There is no doubt the Lions have been a disappointment. The Vikings are what everybody expected, though they did stun San Francisco last week. If the Lions are to be taken seriously, they need to start winning. No better time than the present.
Lions 31-21
DALLAS 4 Chicago
Both teams are pretty good, but I am not sold on Chicago. I am never sold on Dallas as long as Tony Romo is under center. I think Dallas needs this game more because Chicago is suddenly playing in a weaker division, for now. I'll take the Cowboys at home.
Cowboys 23-17
Game of the Week
PHILADELPHIA 2 New York Giants
Michael Vick has been borderline terrible this year, and it is amazing he hasn't gotten seriously hurt. The Giants are good, and could be really good by year's end. I can't trust Michael Vick right now. I can trust Eli Manning. I'll take the Giants in this one.
Giants 26-21
Stinker of the Week
GREEN BAY 7 New Orleans
I can't believe I am doing this, but this has to be the Stinker. I do believe, as do most people, that the Packers should be 2-1. But they are not. The Saints are an unbelievable 0-3. They really miss Sean Peyton. The Packers are likely going to be in a really bad mood, but so are the Saints. I have to take Green Bay. I think the Saints are an absolute mess right now.
Packers 30-20
Record For Week Three: 5-10-1 ( 8-8 without spread )
Record Through Week Three: 20-25-2 ( 27-21 without the spread )
Game of Week Record: 1-2
Stinker of Week Record: 1-2
Jim Poore has been a long time contributor to Patriots Insider with his weekly picks column. Let him know what you think. Email him here:
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These are the gentleman's sport flip flops that help combat the effects of plantar fasciitis with a built-in, podiatrist-designed stabilizing orthotic footbed that realigns feet to a neutral position. The deep heel cups are molded into the flip flops' comfortably soft, shock-absorbing, triple-density EVA footbeds, providing cushioning for the heel and forefoot while aligning the feet into a natural position for those who over-pronate—when the heel bone angles inward—a determining factor in the development of plantar fasciitis. The resilient Vibram outsoles are made from rubber molded with a slip-resistant pattern that grips most surfaces. The durable, flexible leather uppers secure the foot with toe posts. Khaki or Black. Men's whole sizes 7-13. For half sizes, order the next size down. Medium width. (6 oz.)
Lifetime Guarantee
The Gentlemen's Plantar Fasciitis Sport Flip Flops come with The Hammacher Schlemmer Lifetime Guarantee. If this product ever disappoints you, for any reason, you may return your Hammacher Schlemmer purchase for exchange, credit, or refund.
Should you have any questions, we are available seven days a week (8:00 am – midnight EST). Please call 1-800-321-1484 to speak with a specialist or email us at firstname.lastname@example.com to receive a response within three business hours or less.
May we recommend:
(based on 12 reviews)
Ratings Distribution
5 Stars
4 Stars
3 Stars
2 Stars
1 Stars
of respondents would recommend this to a friend.
Best Uses
Feels full size too small
Feels half size too small
Feels true to size
100% (11 reviews)
(11 reviews)
Feels half size too big
Feels full size too big
Feels too narrow
Feels true to width
90% (9 reviews)
(9 reviews)
Feels too wide
Reviewed by 12 customers
Displaying reviews 1-10
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(1 of 1 customers found this review helpful)
Wanted to love them but...
By KP
from Palm Coast, Fl
We were unable to keep these The straps were far on the sides and won't fit unless your feet are fairly thick or wide. This is a first time we've had this problem with fitting flip flops.
Bottom Line No, I would not recommend this to a friend
Hammacher Schlemmer Response: If you are disappointed with a product—for any reason—you may return it under our lifetime guarantee. Please contact our customer service team at 1-800-321-1484 and they will be happy to assist you.
Was this review helpful? Yes / No
- flag this review
Seem to help my Plantar Fasciitis
By Mike
from Orlando, FL
Like to just slip on good Plantar Fascitis support.Wish there was more cushion so I could wear them longer during the day. They seem very durable so far and slip resistant sole is great.
Bottom Line Yes, I would recommend this to a friend
These are very comfortable and have a great arch for support
By Impaler
from Spring Hill, Florida
These are exactly what I was looking for. A flip flop with arch support. They are comfortable, light weight and have a sole that grips.
Best Flip Flops Ever
By ccrider
from North Georgia
Plantar Fasciitis is an ailment with 'good outcomes,' according to medical literature, but normally takes so long to heal that it rivals chronic conditions. The trick is to continue regular treatment at home. These flips allow me to do that. I am noticeably improving with the use of these shoes.
Comfortable, Relieves Pain
By Gillette
from New York, NY
Very comfortable, symptoms of PF gone after a few days.
The Gentlemen's Plantar Fasciitis Sport
By Larry
I've been having pain in the heel of my right foot and have needed orthodic inserts. These feel fine! The only problem is that the strap feels too loose. It should be tighter.
By JERRY THE WALKER
from FLORIDA
A Must Have
By Manny
from Pittsburgh, Pennsylvania
I've recently learned how bad traditional flip flops are for us so I ordered; The Gentlemen's Plantar Faciitis Sports Flip Flop. I hope they never discontinue these as I will always wear them, daily.But know this; you cannot get them wet!
Straps just didn't fit my feet
By mcmikmul
from Sacramento
These are great flip flops; they just don't fit my feet. I have thin feet, so the straps were far too loose for me. I think the assumption is, if you have a long foot (over 12) it is also wide, and large. The footbeds felt good, and appropriately sized.
He Likes Them, He Really Likes Them
By Loving Wife
from Fond du Lac, WI
I bought these for my husband who is having heel pain. He said they help relieve the pain better than regular sandals and even better than his tennis shoes.
COPYRIGHT © 2017 HAMMACHER SCHLEMMER & COMPANY, INC. ALL RIGHTS RESERVED. W107147 E. 57th ST • NEW YORK, NY • 10022 • 1-800-_321-1484


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Research & Publications
We've been doing research and development into educational technology since the Web was young. In that time, we've pioneered whole areas of innovative work and uncovered important findings for the field.
Learn more about the main areas that focus our research and development and take a look at the many articles, books and more we've published.
Focus Areas
Mobile Computing
Mobile computers offer great possibilities for education. We've been exploring them since our founding in 1995.
Modeling & Simulation
Our research into computer-based modeling paves the way for breakthroughs in science, math and engineering learning.
Online Assessment
We're using technology to explore innovative new realms of assessment.
Online Learning
We helped launch the virtual learning revolution over a decade ago, and we're still part of it today.
Our work with probes and sensors provides students powerful new ways of examining the world around them.
Don't miss the latest issue of @Concord, our newsletter about current research and innovation in educational technology.
Published Books
See or purchase our acclaimed books about technology policy, online learning, assessment, and more.
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Seen us – or missed us – at a conference recently? Find materials from our presentations here.
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Read journal articles, white papers, essays and lectures written by Concord Consortium staff.


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Picking crops that would otherwise be left in a garden or field to rot, and sharing them with those in need, is a time-honored idea that's gaining fresh momentum today.
Foraging for food – whether it's ferreting rare mushrooms in the woods, picking abundant lemons from an overlooked tree, or gathering berries from an abandoned lot – is all the rage among the culinary crowd and the D.I.Y. set, who share their finds with fellow food lovers in fancy restaurant meals or humble home suppers.


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Electrical and Computer Engineering
It is a great pleasure to welcome you to the Electrical and Computer Engineering (ECE) Department at Utah State University. The department continues to move ahead, with new faculty joining our ranks in the last year. We are proud to continue the tradition of offering a solid, rigorous undergraduate foundation, with opportunities for specialization and research at the graduate level in areas such as antennas, control systems, signal processing, networking and communication, computer architecture, real-time embedded systems, internet security, and spacecraft instrumentation and systems.
We look forward to hearing from you and seeing you --- prospective and current students, graduate students, and colleagues from around the world. Please contact us if you have any questions.
Jacob Gunther
Department Head


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Yankees Re-Sign LHP Andy Pettitte
The New York Yankees today announced they have re-signed LHP Andy Pettitte to a one-year minor-league contract with an invitation to Major League spring training.
Pettitte, 39, owns a career record of 240-138 (.635) with a 3.88 ERA (3,055.1 IP, 1,317 ER) in 479 starts over 16 Major League seasons with the Yankees (1995-2003 and '07-10) and Houston Astros (2004-06). He is one of just 26 pitchers all-time to be 100-or-more games over .500. Of the 19 Hall of Fame-eligible pitchers who have reached that plateau, only "Parisian" Bob Caruthers, who went 218-99 from 1884-92, is not enshrined in the Baseball Hall of Fame.
Originally selected by the Yankees in the 22nd round of the 1990 First-Year Player Draft, Pettitte has pitched 13 seasons with the club, going 203-112 with a 3.98 ERA (2,535.2 IP, 1,122 ER) and 1,823 strikeouts in 405 games (396 starts). In franchise history, he ranks second in strikeouts and starts, third in wins, fourth in innings pitched and eighth in appearances (405). He has appeared in eight career World Series (seven as a Yankee), winning championships with the Yankees in 1996, '98, '99, 2000 and '09.
Among active pitchers currently in a Major League camp, he ranks second in wins, starts and strikeouts, third in innings pitched and sixth in winning percentage (min. 140 decisions).
Pettitte is the all-time winningest pitcher in postseason history, going 19-10 with a 3.83 ERA in 42 career starts. He also ranks first all time in postseason starts and innings pitched (263.0), and is tied for second with 173 strikeouts.
The left-hander last appeared in the Majors in 2010 with the Yankees, going 11-3 with a 3.28 ERA (129.0 IP, 47 ER) in 21 starts and earning an All-Star team selection. His .786 winning percentage was the highest of his career, the best in the AL and the third-highest in the Majors. In the 2010 postseason, he went 1-1 with a 2.57 ERA (14.0 IP, 4 ER) in two combined starts at Minnesota in ALDS Game 2 on October 7, 2010 (W, 7.0 IP, 2 ER) and vs. Texas in ALCS Game 3 on October 18, 2010 (L, 7.0 IP, 2 ER).
According to the Elias Sports Bureau, Pettitte, a three-time All-Star (1996, 2001, '10) and 2001 ALCS MVP, holds the distinction of being the only pitcher in Major League history to post a record of .500 or better while making at least 15 starts in each of the first 16 seasons of his career. He also posted a winning record in each of the first 13 seasons of his career (1995-2007), marking the third-longest such streak to begin a career all time, trailing only Hall of Famers Grover Cleveland Alexander (17) and Cy Young (15).


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Bring back The Elmers
Yes, I know LinuxCon is next, and that's in mid-August, but I think they've got the publicity thing covered, especially with the 20-year thing and with Linus being there and all. But if you're going to the next show, make it the Ohio LinuxFest in September. Bradley Kuhn and Cathy Malmrose are keynoting, so you'll not want to miss that (especially Cathy — Go ZaReason!)
Brian Proffitt posted an excellent story from LinuxCon North America this morning expanding on the FUD — Fear, Uncertainty and Doubt, for those of you keeping score at home — that has followed Linux over the past 20 years.
Rather than repeat them here, go ahead and check out the story here.
Back in 2007, I proposed — and had a list of nominees — having an award called The Elmers. This award, of course, was named after Elmer Fudd (two Ds, I know), and is given to those who presented the most outrageous and ridiculous FUD. I even missed some of the more classic FUDmeisters in the first item, so I corrected that here.
Now if we could only get Rob Enderle and Ken Hess to be presenters . . . .
This blog, and all other blogs by Larry the Free Software Guy and Larry Cafiero, are licensed under the Creative Commons Attribution-NonCommercial-NoDerivs CC BY-NC-ND license. In short, this license allows others to download this work and share it with others as long as they credit me as the author, but others can't change it in any way or use it commercially.
(Larry Cafiero is one of the founders of the Lindependence Project and has just started developing software in his new home office. Watch this space.)
August 18, 2011 at 3:05 pm
So we might need an Elmer, an Ultimate Elmer and a
Lifetime Elmer?
There has never been anything like Open Source, Linux and
the GPL license so how can anyone predict what will happen?
Linux has been steadily growing, winning new users, moving
into the corporate world and it has done this without much in the way of advertising.
Maybe the FUD Monkeys don't don't deserve recognition.
Peace, Bob
August 22, 2011 at 4:47 am
yes , free backlink for you 😀


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