Austin Travis County Integral Care

A gestão financeira é um dos elementos mais determinantes para a sobrevivência e o desenvolvimento dos empreendedores brasileiros, especialmente em um cenário marcado por burocracia, instabilidade econômica e elevada carga tributária. Este estudo analisa os principais desafios enfrentados pelos pequenos negócios no Brasil, destacando como fatores estruturais, legais e gerenciais influenciam a continuidade das empresas. A pesquisa possui abordagem qualitativa, bibliográfica e descritiva, fundamentada em autores clássicos e contemporâneos da área, além de documentos institucionais. Os resultados demonstram que a falta de planejamento financeiro, o desconhecimento sobre custos e a ausência de estratégias estruturadas contribuem significativamente para a elevada taxa de mortalidade empresarial no país. Observou-se ainda que a complexidade tributária e a insegurança normativa ampliam os custos operacionais e dificultam a formalização de novos negócios. Em contrapartida, empresas que aplicam práticas eficientes de gestão, adotam ferramentas de planejamento e investem em capacitação apresentam maior capacidade de adaptação e desempenho superior. Conclui-se que a profissionalização da gestão financeira, aliada a políticas públicas mais simples e incentivo à educação empreendedora, é essencial para fortalecer a competitividade,reduzir falências e promover o crescimento sustentável dos pequenos empreendimentos no contexto brasileiro.

A sobrevivência empresarial no Brasil é fortemente impactada por fatores como alta carga tributária, burocracia, instabilidade econômica e ausência de práticas estruturadas de gestão financeira. Nesse contexto, o presente estudo teve como objetivo analisar de que forma o planejamento e o controle financeiro influenciam a continuidade de pequenas empresas brasileiras. Para isso, utilizou-se uma abordagem qualitativa, de caráter exploratório, baseada em um estudo de caso realizado com um microempresário do setor de serviços. A coleta de dados ocorreu por meio de entrevista estruturada, que revelou resistência inicial do participante em fornecer informações financeiras, evidenciando a sensibilidade do tema. Os resultados indicaram fragilidades significativas na gestão do empreendimento, como ausência de planejamento formal, desconhecimento sobre o teto de faturamento, inexistência de reserva financeira capaz de cobrir três meses de despesas e dependência de aportes pessoais para manter a operação. O entrevistado também destacou a elevada carga tributária como um dos principais desafios à sustentabilidade do negócio. Conclui-se que a sobrevivência empresarial depende de práticas financeiras eficazes, planejamento estratégico, acompanhamento regular de obrigações fiscais e maior acesso à capacitação. Assim, reforça-se a importância de políticas públicas e apoio institucional que fortaleçam pequenos empreendedores.

Our primary objective evaluated the perception of emergency medical service (EMS) providers' review of automated hospital outcome data. Secondarily, we assessed participation in outcome review as a means of microlearning to obtain continuing education (CE). From October-December 2023, three high-volume EMS systems participated in a three-part intervention with results evaluated using a mixed-methods approach. First, EMS providers (emergency medical technicians and paramedics) were invited, via their electronic health record (EHR), to complete a presurvey evaluating their perceptions of reviewing outcomes. Then, EMS providers were notified about the opportunity to earn CE via a microlearning intervention, offering Commission on Accreditation for Pre-Hospital Continuing Education (CAPCE)-approved CE hours for completion of outcome reviews and associated learning modules. Finally, EMS providers were invited to complete a post-survey mirroring the pre-survey. Qualitative analyses identified themes among open-ended responses. Quantitative analyses examined perceptions between pre- and post- surveys. Of 843 providers contacted, 217 responded to the pre-survey (25.7%). The most endorsed rationale for reviewing outcomes included improving clinical knowledge (95%), improving patient care (94%), and knowing whether care made a difference (93%). Nearly all (91%) reported being more likely to review outcomes if CE were awarded. Among the 67 who completed the open-ended items, the three dominant themes included enhance personal confidence and competence (43%); acquire personal knowledge (39%); and operations (21%). Of 211 providers who participated in the intervention, 56 (27%) were awarded CE. A total of 152 providers responded to the post-survey, and the percentage who agreed that reviewing outcomes improves job satisfaction rose from 89% to 95% between pre- and post-surveys (P = 0.05). EMS providers supported the personal and professional development and patient care improvement of reviewing patients' outcomes with associated CE. Further study is warranted to evaluate the generalizability of these findings and the best user experience.

Cigarette smoking remains the leading cause of preventable disease and death in the United States. Brief discussions with doctors increase cessation rates by two-thirds, and physicians trained in smoking cessation are more likely to perform counseling. Multiple organizations also recommend connecting counseling with lung cancer screening (LCS), yet physicians and patients report a lack of such integration. We sought to characterize the education received and the barriers to providing smoking cessation counseling, and to determine its integration with LCS among military Family Medicine physicians. This is a cross-sectional study of registered attendees of 2022 Uniformed Services Academy of Family Physicians Annual Conference. Our study aimed to: (1) Assess the amount of formal smoking cessation education during and after residency; (2) assess barriers to providing smoking cessation within the military health care system; and (3) assess if physicians connect smoking cessation counseling and LCS. Descriptive statistics with chi-squared analysis were used to analyze the survey results. With a response rate of 61% (n = 323/487), most participants reported receiving <3 sessions of formal education during residency (72.9%) and <3 h after residency (76.2%). Forty-eight percent cited their health care system never or rarely provided resources on smoking cessation. Time was the largest barrier to promoting smoking cessation (62.6%) and to integrating it with LCS (56.7%), although a considerable percentage also cited lack of supporting staff (34.3%). Furthermore, only 50.6% of respondents always reported counseling on smoking cessation with LCS. Smoking cessation education is provided in family medicine residencies but rarely offered afterwards. Time and lack of support staff and resources are recognized as notable barriers within the military health care system. A large proportion of uniformed Family Medicine physicians also do not link LCS guidelines with patient education on tobacco cessation and resources. Further research is needed to guide interventions to overcome these challenges within the military health care system.

Objectives Emergency medical services (EMS) systems increasingly grapple with rising call volumes and workforce shortages, forcing systems to decide which responses may be delayed. Limited research has linked dispatch codes, on-scene findings, and emergency department (ED) outcomes. This study evaluated the association between dispatch categorizations and time-critical EMS responses defined by prehospital interventions and ED outcomes. Secondarily, we proposed a framework for identifying dispatch categorizations that are safe or unsafe to hold in queue. Methods This retrospective, multi-center analysis encompassed all 9-1-1 responses from 8 accredited EMS systems between 1/1/2021 and 06/30/2023, utilizing the Medical Priority Dispatch System (MPDS). Independent variables included MPDS Protocol numbers and Determinant levels. EMS treatments and ED diagnoses/dispositions were categorized as time-critical using a multi-round consensus survey. The primary outcome was the proportion of EMS responses categorized as time-critical. A non-parametric test for trend was used to assess the proportion of time-critical responses Determinant levels. Based on group consensus, Protocol/Determinant level combinations with at least 120 responses (∼1 per week) were further categorized as safe to hold in queue (<1% time-critical intervention by EMS and <5% time-critical ED outcome) or unsafe to hold in queue (>10% time-critical intervention by EMS or >10% time-critical ED outcome). Results Of 1,715,612 EMS incidents, 6% (109,250) involved a time-critical EMS intervention. Among EMS transports with linked outcome data (543,883), 12% had time-critical ED outcomes. The proportion of time-critical EMS interventions increased with Determinant level (OMEGA: 1%, ECHO: 38%, p-trend < 0.01) as did time-critical ED outcomes (OMEGA: 3%, ECHO: 31%, p-trend < 0.01). Of 162 unique Protocols/Determinants with at least 120 uses, 30 met criteria for safe to hold in queue, accounting for 8% (142,067) of incidents. Meanwhile, 72 Protocols/Determinants met criteria for unsafe to hold, accounting for 52% (883,683) of incidents. Seven of 32 ALPHA level Protocols and 3/17 OMEGA level Protocols met the proposed criteria for unsafe to hold in queue. Conclusions In general, Determinant levels aligned with time-critical responses; however, a notable minority of lower acuity Determinant level Protocols met criteria for unsafe to hold. This suggests a more nuanced approach to dispatch prioritization, considering both Protocol and Determinant level factors.

Individuals with behavioral health conditions account for 50% of annual smoking-related deaths, yet rarely receive tobacco dependence treatment within local mental health authorities (LMHAs). As lack of training and knowledge are key barriers to providing tobacco dependence treatment, Taking Texas Tobacco-Free (TTTF) developed an iterative, 4–6-months train-the-trainer program to embed expertise and delivery of sustained education on tobacco-free workplace policies and practices in participating centers. We explore the employee “champions’” train-the-trainer program experiences using a community of practice (CoP) model to identify key contributors to successful program implementation. Across 3 different LMHAs, we conducted semi-structured individual and group interviews online at 2 time points. We interviewed each champion twice (except for 1 champion who dropped out between measurements); pre-implementation (3 group interviews; N = 4 + 4 + 3 = 11 champions); post-implementation (7 individual interviews and 1 group interview; 7 + 3 = 10 champions). Therefore, 11 champions participated in pre- and post-implementation interviews from July 2020–May 2021. Guided by an iterative, thematic analysis and constant comparison process, we inductively coded and summarized data into themes. Five factors contributed to successful program implementation: value of peer support/feedback; building knowledge, champion confidence, and program ownership; informative curriculum, adaptable to targeted populations; staying abreast of current tobacco/nicotine research and products; and TTTF team responsiveness and practical coaching/assistance. Champions reported the TTTF train-the-trainer program was successful and identified attitudes and CoP processes that effectively built organizational capacity and expertise to sustainably address tobacco dependence. Study findings can guide other agencies in implementing sustainable tobacco-free training programs.

Tobacco use is exceedingly high among individuals receiving care for opioid addiction, but not commonly addressed by clinicians in treatment settings. Taking Texas Tobacco Free (TTTF) is a comprehensive tobacco-free workplace (TFW) program that builds treatment centers’ capacity to address tobacco use with evidence-based tobacco cessation policies and practices. Here, we examine the process and outcomes of TTTF’s implementation within 7 opioid addiction centers. Program goals were structured according to the RE-AIM framework. Pre- and post-implementation data were collected from client facing and non-client facing employees to assess changes in education, training receipt, knowledge, and intervention behaviors, relative to program goals. Centers reported tobacco screenings conducted and nicotine replacement therapy (NRT) delivered through 6 months post-implementation. Overall, 64.56% of employees participated in TTTF-delivered tobacco education, with a 54.9% gain in tobacco control and treatment knowledge (p < 0.0001), and significant increases in exposure to education about tobacco use and harms among individuals with opioid use disorder (p = 0.0401). There were significant gains in clinicians’ receipt of training in 9/9 tobacco education areas (ps ≤ 0.0118). From pre- to post-implementation, there were mean increases in the use of the 5A’s (ask, advise, assess, assist, and arrange) and other evidence-based interventions for tobacco cessation, with statistically significant gains seen in NRT provision/referral (p < 0.0001). Several program goals were achieved or exceeded; however, 100% center participation in specialized clinical trainings was among notable exceptions. One program withdrew due to competing pandemic concerns; all others implemented comprehensive TFW policies. Overall, TTTF may have improved participating opioid treatment centers’ capacity to address tobacco use, although study limitations, including lower post-implementation evaluation response rates, suggest that results require replication in other opioid addiction treatment settings.

Despite prior successful implementation of Taking Texas Tobacco Free (TTTF), an evidence-based tobacco-free workplace program, in local mental health authorities (LMHAs), post-implementation employee attrition necessitated continuing education on tobacco-free policies and tobacco treatment practices. Here, we report on the outcomes of a train-the-trainer program which trained “champions” to deliver tobacco cessation education at their LMHAs. Three LMHAs participated in program implementation via 10 champions, iteratively trained and coached by TTTF. Measures administered evaluated four goals: (1) increase champions’ self-efficacy in delivering trainings, (2) achieve program fidelity via TTTF staff evaluation of trainer effectiveness and knowledge increases among attending employees, (3) achieve stakeholder program acceptability, and (4) achieve program adoption via an increase in follow-up trainings. Champions’ self-efficacy increased throughout TTTF training. TTTF staff ratings of champion-led trainings met the targeted range for trainer effectiveness; employees had a 28.71% knowledge increase over baseline post-training (p < 0.001). Employees rated champions’ training delivery “very good” to “excellent”, on average; both champions and employees were, on average, “satisfied” to “extremely satisfied” with the curriculum and training received. There was an increase over baseline in trainings delivered during follow-up, and trainings increased in length and topic coverage. Ultimately, the train-the-trainer program achieved the intended goals, although not all changes were statistically significant, likely at least partially attributable to small sample sizes. Overall, these results suggest that TTTF’s train-the-trainer program was successful in its delivery and intention to build capacity for the provision of in-house tobacco education trainings to behavioral health employees/providers. However, further evaluation in additional settings, with more champions, et cetera, is necessary to validate these findings, ensure their replicability, link program implementation with reduced patient tobacco use rates, and assess long-term sustainability.

Tobacco use is disproportionately elevated among patients with substance use disorders relative to the general U.S. population. Tobacco interventions are lacking within substance use treatment centers (SUTCs) due to lack of knowledge and training. This study examined knowledge gain and the organizational factors that might moderate knowledge gains following tobacco education training provided to employees (N = 580) within 15 SUTCs that were participating in a tobacco-free workplace program. The number of total annual patient visits, unique annual patient visits, number of full-time employees, and organizational readiness for implementing change (ORIC) as assessed prior to implementation were examined as potential moderators. Results demonstrated significant knowledge gain (p < 0.001) after training overall; individually, 13 SUTCs had significant knowledge gain (p’s < 0.014). SUTCs with fewer total annual patient visits and fewer full-time employees showed greater knowledge gains. The ORIC total score and all but one of its subscales (Resource Availability) moderated knowledge gain. SUTCs with greater initial Change Efficacy (p = 0.029), Valence (p = 0.027), and Commitment (p < 0.001) had greater knowledge gain than SUTCs with lower scores on these constructs; SUTCs with greater Task Knowledge (p < 0.001) regarding requirements for change exhibited less knowledge gain. Understanding the organizational-level factors impacting training effectiveness can inform efforts in organizational change and tobacco control program implementation.