The assessment and treatment of a diabetic ulcer with be discussed. The WritePass Journal

The assessment and treatment of a diabetic ulcer with be discussed. Introduction The assessment and treatment of a diabetic ulcer with be discussed. IntroductionThe phases of normal wound healing   Inflammation – a reaction to tissue damage / infection   Reconstruction – granulation tissue starts to form.   Epithelialisation – the wound becomes covered with epithelial cells.   Maturation – scar tissue starts to fade and blend in with the normal tissueCase StudyREFERENCESRelated Introduction For this tissue viability assignment the assessment and treatment of a diabetic ulcer with be discussed. Wound healing and it properties will also be mentioned in regards to holistic factors affecting the chosen patient (pt).   In accordance with the Health Professional Council (HPC) a standard of conduct, performance and ethics, a pseudonym has been used to protect the identity of the pt discussed (HPC 2008).  Ã‚   I certify that confidentiality has been maintained, for the purpose of this assignment the patient will be called Mr Sim.An ulcer is a defect effecting loss of epidermis and all or part of the dermis (Lookingbill Marks 1993).   The skin comprises of three layers, and is the largest organ in the body. The average adult has 21 square feet of skin   (2 sq m)   weighing up to 3.2 Kg (Benbow 2007). The three layers of the skin are, the Epidermis   this consists of dead skin cells which shed continuously and it protects against certain bacteria.   The epidermis also acts as a barrier to prevent evaporation and absorption of water.   The Dermal Layer consists of capillaries, sebaceous (oil) glands, sensory receptors which transmit sensations such as itch, pain and temperature, and hair follicles all held together by elastin and collagen. The Subcutaneous layer contains fat and connective tissue that houses larger blood vessels and nerves. This layer is important in the regulation of temperature of the skin itself and the body. The size of this layer varies throughout the body and from person to person (Brannon 2007). The skin is a complicated structure with many functions. If any of the structures in the skin are compromised through poor blood supply, trauma, surgery etc. a wound may develop. â€Å"A wound is a loss of continuity to the skin â€Å"states Dealey Cameron (2008) The phases of normal wound healing    Inflammation – a reaction to tissue damage / infection    Reconstruction – granulation tissue starts to form.    Epithelialisation – the wound becomes covered with epithelial cells.    Maturation – scar tissue starts to fade and blend in with the normal tissue Case Study The subject of this study is a male patient aged 69 years, for the purpose of this case study the patient will be referred to as Mr Sim.   Mr Sim attended as a new patient to the podiatry department at his local clinic complaining â€Å"something has been catching on my socks†. On examination of Mr Sim’s foot a large area of callus was observed on the plantar aspect of his right fifth toe (ball of foot under little toe) there was some brown discolouration due to extravasation (leakage of blood into the skin) indicating that there could be an ulcer under the callus. It was explained to Mr Sim that further assessment and treatment would be necessary to determine what and why the problem was occurring. The podiatry assessment tool was used to provide a holistic approach to assessment of medical history and social factors that may affect the foot health of the patient.   The tool has a systematic problem based approach to undertaking clinical assessment and a detailed history; it is similar in outlay to a Patient Orientated Medical Review (POMR).   Both the POMR and the podiatry assessment tool include a description of the presenting complaint which is an important part as it determines what the patient considers to be important and can be used to establish agreed expectations.   Both models include previous and current medical history including any operations, illnesses or injuries which is of high importance in wound healing as systemic disorders or medication can have a large impact on wound healing. Both assessment tools include a detail of any known allergies, any family traits and social factors such as smoking or drug taking.   The factors assessed in the above tools are recognised as being significant factors in wound healing. Rainey (2005) lists medication, illness, smoking, alcohol consumption and mobility as factors that affect wound healing.   In addition to the POMR the podiatry assessment tool focuses on the factors that may affect the patients foot health for example previous or current occupations, an appraisal of the patient’s footwear and assessment of patients gait, vascular assessment, condition of skin, skin colour, skin temperature as well as palpating pedal pluses. A neurological assessment using a 10 gram monofilament, which is the standard neuropathy test in primary and community care in the united kingdom since National Institute for Clinical Excellence (NICE) guidelines for the management of the diabetic foot were published in 2004 (Boulton et al 2006).   However the podiatry assessment tool does not include an assessment of the nutritional status of a patient which has been regarded as a key factor affecting wound healing (Dealey 2005, Rainey 2005), and malnutrition is a very important cause in delaying the healing process (Morrison 1992). Using the podiatry assessment tool it was found that Mr Sim was diagnosed with Type 2 diabetes nine years ago and had recently moved to the area from abroad after losing his wife of to whom he was married to for forty four years, he now lives in the same road as his nephew.   Mr Sims has good control of his diabetes taking metformin 500m mg twice daily, his recent HBA1C was 7.3 % this is regarded as tight glycaemic control (Lee et al 2006) His nutritional status adequate, he reports no strong family history of diabetes or heart disease, he occasionally has a glass of red wine.   Mr Sims also takes medication to control hypertension (high blood pressure), bendroflumethiazide and aspirin, a cholesterol tablet as a precautionary method, and painkillers and antiflammatory treatment for osteoarthritis. He also mentioned that the pain in his back was increasing, and was taking a course of antibiotics for an infected cut on his hand obtained whilst gardening.   For some time now he ha d been experiencing bouts of tingling in both his hands and feet.   He expressed that he takes good care of himself never smoked, eats well and keeps active, and he states he has â€Å"an awareness of the importance of good footwear as I was in the army†. All patients with diabetes should receive an annual foot check by a trained health care professional (NICE 2004), this includes the application of a 10g monofilament to five points on each foot, to assess the protective sensation in the feet and the extent of any sensory neuropathy. Peripheral sensory neuropathy is thought to affect 20 – 40% of the population (McIntosh et al 2004) and is a major factor in the development of diabetic foot ulceration. Both feet were tested using the 10g monofilament this resulted in 0/5 probes being detected on both feet indicating peripheral neuropathy, however the dorsalis pedis and posterior tibialis were palpable in both feet, skin colour, texture and temperature and capillary refill was 2 seconds indicating good blood supply (Dealey 2005). Baker, Murali and Fowler (2005) state that the palpation of foot pulses is not a good indicator for a good blood supply.   A Doppler gives a more accurate result when assessing vascular status it assists the diagnosis by determining the presence or absence of a compromised arterial flow in the lower limb (Dughil 2006) Jeng et al (2000) concluded that if a person cannot identify the pressure from a 10g monofilament on their skin approximately 98% of the sensory ability has been lost. When the 10g monofilament is applied to the foot it buckles at a given force of 10g, inability to feel this is a significant indication that neuropathy is present and protective pain sensation is lost (Edmonds and Foster 2000). Neuropathy presents itself in various ways; motor, sensory and autonomic nerves are affected and there is no conclusive proof as to what causes neuropathy.   Factors such as high glucose levels can cause chemical changes, harming blood vessels, which supply oxygen, to tissue.   Motor neuropathy, causes abnormal foot pressures, the structure of the foot can change, giving abnormal pressure areas. Sensory neuropathy can give reduced sensation, masking pain, allowing for callus build up, and leading to ulceration.   Autonomic neuropathy, which leads to dehydration of the skin, is commonly known as arteriovenous shunting (A.V).   Neuropathy is detected by using a 10g monofilament. This is used on high pressure areas to detect if the patient can feel pain or not. These results, however, may not always be reliable, as they rely on patient feedback, therefore clinical judgement, must always be upheld at all times. Diabetes affects the vascular supply to the foot, leading to reduce or absent pulses, causing poor tissue viability, decreasing healing time. Excess glucose and cholesterol deposits in the lumen of blood vessels, reducing the diameter, which in turn, increases heart activity causing hypertension.   Aspirin is used as a prevention, it is classed as an anti-platelet drug which reduces platelet aggregation.   Aspirin inhibits enzyme COX, which reduces platelet production of TXA2, which is a powerful vasoconstrictor. Mr Johnson* is currently taking Atenolol, hypertensive drug as well as Aspirin to reduce the chances of thrombosis or MI. It was explained in detail to Mr Sim about the complications of diabetes and how it may affect the feet, during the discussion Mr Sim became upset about the loss of his wife, â€Å"she always looked after my feet particularly because of the diabetes†.   It was important to establish a good rapour with Mr Sim, as the lesion was causing him no discomfort apart from catching on his socks.   The recent loss of his wife, his back pain and hand infection had put a lot of stress on Mr Sim.   Depression is twice as likely to occur in people with diabetes and this can have a link to fluctuating blood sugar levels.   Mr Sim is also experiencing pain from his back and is still grieving about the death of his wife and coming to terms with living alone.   Stress is recognised as a factor in delaying wound healing (Dealey 2005; Glasser et al 1999; Kiecolt-Glasser et al 1995).   Cole-king and Harding (2001) found a statistically significant relationship between anxiety and depres sion and delayed in chronic wounds.   Communicating with patients can reduce anxiety and promote the natural healing process, conversely lack of communication may impair healing (Collier 1994) It was then explained to Mr Sim extenslevily about the lesion of his foot in regards to his general health without adding to his stress levels.   Education has proven to be vital in the management of diabetes (NICE) .   It was suggested that on debridement of the callus that there could possibly be foot ulcer, with Mr Sim’s consent the callus was removed using sharp debridement an ulcer was revealed.   The ulcer measured 1cm x 1cm and probed to a depth of 5mm to tendon but not to bone, the base of the was ulcer was sloughy and yellow and appearance showed no sign of infection, sharp debridement was   used   very carefully to remove slough.   Slough in the base of an ulcer is an ideal breeding ground for bacteria which increases the risk of infection and delays healing (Rainey 2005).  Ã‚   If infection was noted healing will be delayed and may spread to surrounding tissue or bone. At the time of assessment Mr Sim’s ulcer showed no signs of infection, althou gh he was taking a course of antibiotics for the infection in the wound on his hand. Diabetic problems such as peripheral ischemia or neuropathy can mask signs of infection this was considered on assessment. The wound following sharp debridement was flat and pink, this was significant as rolled edges would indicate infection. The condition of the skin was dry and showed no signs of maceration. The use of tool to grade the ulcer can provide objectivity and help with communication between health professionals.   The tool used in this study was EPUAP European Pressure Ulcer Advisory System 1998, in this case the ulcer was caused by excess pressure   over an area affected by peripheral sensory neuropathy.   There are many wound classification systems including SAD, SINBAD and PEDIS, however the EPUAP grading system was protocol for this particular community trust.   The ulcer was classified as a grade four pressure ulcer which is described as extensive destruction tissue necrosi s, or damage to muscle, bone or supporting structure with or without full thickness loss. The choice of dressing being â€Å"Activon Honey Tulle† produced by Advancis medical the gauze is impregnated with pure Manuka honey, this was used firstly to complete the debridement autolyticly.   Secondly for the antimicrobial purposes and its aid to deslough and control odour in the wound.   Benbow (2008) states a mosit environment is essential for optimal wound healing.   Other dressings are considered also for their topical antimicrobial agents, such as Iodine and Silver.   Iodine was an option although none where available in Clinic.   Iodine is a popular choice for the use in Podiatry. Silver dressings are more expensive than the honey and also should only be used when there is clinical sighs of infection (British national Formulary: BNF, Nov 2009), so, as in Mr Sim’s case there was no signs.   The secondary dressing was a foam dressing designed to absorb and retain any wound exudate to stop the wound from becoming macerated and inhibiting wound heal ing. ‘Biatain’ was the dressing choice as this is one of the foam dressings used in the clinics.   This was needed as the Activion Tulle does not have any absorption properties.   These dressing were held in place with ‘Mefix’ an adherent tape.   Mr Sim was given instructions to keep the dressing clean and dry until his next appointment Holistically the treatment plan was to contact Mr Sim’s, G.P regarding his depression over the loss of his wife, and referral to the local diabetes centre.   A lengthy discussion was held on the importance of good footwear and changing shoes regularly, as although Mr Sim’s shoes where good shoes they were very old and the innersole had worn out penetrating to the outer sole (hole in bottom of shoe).   A total contact insole referral was made to relieve the pressure long term.   Temporally a pad was mad to deflect pressure away from the ulcer overlying the dressing in situ.   Effective reduction in pressure relief is essential to heal a diabetic foot ulcer and to prevent reoccurrence (Armstrong et al 2001).   A education booklet was supplied titled Diabetic foot Ulcer, if a patient has the knowledge and understanding of their treatment plan they are More likely to comply (Dowsett 2004). Mr Sim was as asked to return to clinic in five days as part of his dressing regime, he reported he had an appointment with the G.P the following day to discuss his depression. He had also received a letter from the diabetes centre with an appointment for the following week.   The NSF (National Service Framework) and NICE the National Institute for Clinical Excellence set standards and put polices in place for every health care professional to follow, all patients with diabetes present with an ulcer must be referred on to a multidisciplinary team to receive the best care possible. The multidisciplinary team consists highly trained podiatrist, diabetologist, consultant, nurses, orthotists all of which specialises in complications of the foot and lower limb (NICE 2004). The dressing was removed the wound measured a reduction in depth and circumference 7mm x 6mm depth 3mm, exudate levels where low, there were no clinical signs of infection, no maceration or further callus formation, the same dressing was applied and along with padding. A further appointment was made for seven day’s time , ideally the dressing change should be five days but due to staff sickness this was not possible. At this appointment Mr Sim had seen the G.P who had referred him to a bereavement councillor.   The diabetes Centre had furthermore made a referral to the orthopaedic department who are fitting Mr Sim for orthopaedic footwear for pressure relief in accordance with NICE guidelines (2008). On conclusion the outcome for this case study was a positive one, the patient was assessed holistically to identify and factors which may hinder the healing process, this not only includes the factors directly affecting the wound but also indirectly by affecting the patients qua lity of life including dealing with bereavement, housing issues etc.   The Department of Health (DH 2008) stated â€Å"Delivering improvements for people with long term conditions is not just about treating illness, it is about delivering personalised, responsive, holistic care in the full context of how people live their lives.   Our journey to achieve this has started, our challenge is to continue to take it forward and the evidence compels us to do this†. REFERENCES HPC Armstrong, D.G., Nguyen, H.C Lavery, L. A., (2001) offlanding the diabetic foot wounds. Diabetes care 24 (6) 1019 1022 Baker, N., Murali-Krishman, S., Folwer, D (2005) A users guide to foot screening, part 2, peripheral arterial disease, the diabetic foot 8 (2) 58-70 Benbow M (May 2007) Back to Basics – Skin and Wounds. Journal of Community Nursing Vol 21 (5) p34 Benbow M   (2010) Ageing Wound healing, Journal of community nursing. 24 (5) 36-38 Brannon, H M.D   former about.comguide Collier, M (1994) assessing a wound. Nursing standard 8 (49): 3-13 Dealey, C. (2005). The care of Wounds. A guide for Nurses. Blackwell Science, oxford. Dowssett (2004) Dughill, S., (2006) peripheral arterial disease. Why screen in primary care?   Nursing times 102 (16) 38-39 Glaser, R., Kiecolt-Glaser, J.K., Marucha, D.M.D MacCallum, R.C., Laskowski, B.F., and Malarkey, W.B (1999). Stress-related changes in pro inflammatory cytokine production in wounds.   Archives of General Psychiatry 56 (5), 450-456. Cited in Dealey, C. (2005). Marcucha, P.T., Malarkey, W.B., Mercado, A.M Glaser, R. (1995).  Ã‚   Slowing of wound healing by psychological stress. Lancet, 346 (8984) 1194-1196. Cited in Dealey (2005) Rainey, J (2005). Wound Care, A handbook for community Nurses. Whurr Publishing, London.   Lookingbill ,D,P. Marks, J, G (1993) principles of Dermatology. London; W.B Saunders company.

An Overview of Delta Dental Insurance Essay Example for Free

An Overview of Delta Dental Insurance Essay This paper provides an overview of Delta Dental – one of the most successful health care companies in the United States. As good oral health becomes more essential of Americans’ healthy lifestyle, Delta Dental insurance plans help more than 59.5 million people to be covered on their plans. By describing the outline of Delta Dental’s history and current structure, this article focuses on how Delta Dental insurance has grown and improved access and overall health status. Also, this paper explores strengths and weaknesses (especially with healthcare delivery point of view) as well as makes comparison with other dental insurances companies to reveal that why Delta Dental is better and more successful than others. Finally, the future plans of Delta Dental about how to improve oral care delivery of services to clients and enrollees, as well as how it fared compare to its peer insurance companies are initialed at the end of the paper. Keywords: dental benefits programs, strengths and weaknesses, multiple types, expanding, effective benefits Many people in the world may have best access to oral health care, yet millions are unable to get basic dental care. Poor oral hygiene has significant impact on overall personal health. Researches show that poor oral hygiene increases the risk of diabetes, heart disease and poor birth outcome. That’s why nobody can deny the importance of oral health care. According to many statistics insurance companies that play a pivotal role in improving oral health care of the communities, we will focus on the Delta Dental insurance and how growth of the company improved access and overall health status. Delta Dental insurance was established in 1966. Over the years it faces many challenges to expand and increase access of dental care in community. The efforts paid the Delta Dental as widely accepted by community. This paper focuses on challenges Delta Dental had to face to build its pillar in the market. After evolution, Delta Dental insurance exponentially expanded due to its benefits and low primer. Over the years it has made strategies so that many people prefer Delta Dental over other insurances for maximum benefits, which helped improve oral health care. This paper will also highlight some of those strategies. Compare to other dental insurance company, Delta Dental insurance provide wide coverage and offer maximum benefits. This is a unique characteristic of the Delta Dental. We will talk about current structure of the Delta Dental and its future about how to improve oral care delivery of services to clients and enrollees, as well as how it fared compare to its peer insurance companies. Finally, the paper will mention about the future plan of the Delta Dental. In order to increase access to oral health care, in 1954, a group of dentists formed a dental service corporation in California, Oregon and Washington. It was lead by Washington Dental Service (WDS), and initiated by providing service to organized labor unions. Later, it expanded its services to all 50 states, the District of Columbia and Puerto Rico. Delta dental is now a fifteen billion dollar a year nationwide group providing dental insurance to 59 million Americans, making it one of the largest non-profits in the country (â€Å"Our Mission & History†, n.d.). Washington Dental Service was joined by more local organizations, which then created Delta Dental Plans Association (DDPA) in 1966. Shortly a year after, WDS partnered with the International Association of Machinists, which was the first step into creating a multi-state dental benefits program. There was a growing number of out of state subscribers, and therefore in order to meet their needs WDS worked with other Delta Dental member companies and Blue Cross/Blue Shield Association members, to continue serving its clients. It provided coverage until 1980’s this way (â€Å"Our Mission & History†, n.d.). The program continued as such until a bid was won by Delta Dental of California being chosen as the dental benefits carrier for the Office of the Civilian Health and Medical Program of the Uniformed Services (OCHAMPUS) program. In order for the administration of this very large account to be centralized, other member companies agreed to share its provider data with Delta Dental of California sharing the administrative income and risk. As a result of this change, the National Provider File (NPF), and the establishment in 1990 of Delta USA — was created, the company responsible for overseeing dentist data and enabling the administration of national business (â€Å"Our Mission & History†, n.d.). Currently, there are 39 independent Delta Dental member companies operating in all 50 states, the District of Columbia and Puerto Rico. As one of the largest dental benefits provider DDPA provides coverage to more than 59.5 million people enrolled in more than 97,000 groups. The company was named Dental Care until 1970’s and then it officially changed its name to Delta Dental (â€Å"About Us Home†, n.d.). All Delta Dental companies are members, or affiliate of members, of the Delta Dental Plans Association – a network of 39 Delta Dental companies throughout the country. Delta Dental companies range from multi-state to single state (â€Å"About Us Home†, n.d.). The multi-state programs consist of the following: Started in 1969, it provides coverage to over 1.5 million residents of New Jersey and Connecticut (â€Å"Delta Dental of New Jersey†, n.d.). * Delta Dental Plan of Michigan Michigan Dental Service (MDS) was established in 1957, and in 1963 it received its non-profit status. In 1980 MDS expanded to Ohio and Indiana. In early 2006, Delta Dental of Michigan, with its affiliates in Ohio and Indiana, and Tennessee, signed an affiliation agreement under a new nonprofit holding company to strengthen their market positions and increase the number of Americans with dental benefits. In 2009, Delta Dental of Kentucky and Delta Dental of New Mexico affiliated with the family of companies. The newest affiliate, Delta Dental of North Carolina, joined the enterprise in 2010. Currently they cover 8.8 million individuals (â€Å"Delta Dental of Michigan†, n.d.). It was founded in 1969, and later expanded to North Dakota. It is the largest program in the upper Midwest, serving 7500 Minnesota based on purchasing groups and 3.8 million members nationwide (â€Å"Delta Dental of Minnesota†, n.d.). Delta Dental of Missouri started 50 years ago and has offered dental and vision benefits in the states of Missouri and South Carolina. More than 1,800 companies in Missouri and South Carolina have selected Delta Dental as their dental benefits carrier. The Delta-Vision plan started in 2011 (â€Å"Delta Dental of Missouri†, n.d.). Dentegra is not affiliated with Delta Dental Plans Association. However, this insurance company is authorized by Delta Dental Plans Association to market and underwrites certain national Delta Dental programs. This plan covers 23 million Americans. It serves the states of: Alabama, California, Delaware, District of Columbia, Florida, Georgia, Louisiana, Maryland, Mississippi, Montana, Nevada, New York, Pennsylvania, Puerto Rico, Texas, Utah, Virgin Islands, West Virginia (â€Å"Why do more than†, n.d.). Hawaii Dental Service (HDS) is the first and largest nonprofit dental service corporation in Hawaii providing dental benefit plans to more than a half million members. This plan was incorporated on February 15, 1962, and soon 221 licensed dentists became charter members. HDS serves Guam, Hawaii and Northern Mariana Islands (â€Å"Caring, Visionary Dentists From HDS†, n.d.). NDD offers the states of Maine, New Hampshire, Vermont, providing quality dental care to millions of residents (â€Å"Northeast Delta Dental†, n.d.). This plan covers Alaska and Oregon. A research to find affordable dental health by Longshoremen’s and Warehousemen’s Union, led them to find Oregon Dental Service in 1955(â€Å"A trailblazer in health†, n.d.). * The single state companies include: Delta Dental of Arizona that started in 1972. Delta Dental of Arkansas, Delta Dental of Colorado began in 1958. Delta Dental of Idaho, Delta Dental of Illinois, Delta Dental of Iowa, Delta Dental of Kansas, Delta Dental of Massachusetts, Delta Dental of Nebraska, Delta Dental of Oklahoma, Delta Dental of Rhode Island, Delta Dental of South Dakota, Washington Dental Service, Delta Dental of Wisconsin, Delta Dental of Wyoming (â€Å"Delta Dental: Members†, n.d.). Delta Dental offers various plans for individuals, families and enrollees. There are 39 member companies of Delta Dental and each of them provides a variety of dental benefits programs. It also forms contacts with small and large business companies to provide dental insurance coverage for their employees (â€Å"Products and Plans†, n.d.). The various plans offered are the following: 1. Delta Dental Premier ®: This is their traditional fee-for-service plan with largest dentist network with more than four out of five nation’s dentist participating (â€Å"Delta Dental Premier ®Ã¢â‚¬ , n.d., p. 2). It allows patients to get treated by any licensed dentist and also can change dentists at any time without notifying Delta Dental. The main attraction for this plan is that you do not have to pay more than the co-insurance percentage specified by your coverage (â€Å"Delta Dental’s plans†, n.d.). The participating dentists agree to accept pre-negotiated fees and are prohibited from billing more. 2. Delta Dental PPOâ„  : This is a mid-priced fee-for-service plan with the secondary largest dentist network. It has an option to get treated by any dentists and still have lower out-of-pocket costs because the dentists in this network have agreed to do so (â€Å"Delta Dental’s plans†, n.d.). It also has a Delta Dental PPO plus Premier plan which includes all the benefits of Delta Dental PPO and also allows for a patient to see a Delta Dental Premier dentist with benefits of that dentist’s contracted fee (â€Å" Delta Dental PPOâ„   †, n.d.). 3. DeltaCare ® USA: It is a HMO-type prepaid plan with a large network of participating dentists. You must select a dentist from their network for this plan. The main features are there is no annual deductibles, no maximums for covered benefits and set copayments (â€Å"Delta Dental’s plans†, n.d .). 4. Delta Dental Individual and Family: Individual and its family can get the same quality dental benefits as provided by the employers under this plan. Delta Dental offers different plans in different states (â€Å"Delta Dental Individual and Family†, n.d.). 5. Delta Dental Legion ®: It is also known as TRICARE Retiree Dental Program. â€Å"The first and only dental benefits plan created by Congress especially for Uniformed Services retirees and their family members and administered by Delta Dental of California.†(â€Å"TRICARE Retiree Dental Program†, n.d.). 6. Delta Dental Patient Direct ®: It is a dental discount plan for individual, families and groups that do not have dental benefits. The patients choose dentists from the network and pay them directly with the discount price at the time of their treatment. No paper work is required and it is available in the selected markets only (â€Å"Delta Dental Patient Direct ®Ã¢â‚¬ , n.d.). 7. DeltaVision ®: This is vision benefit plan, which is offered in the selected markets only. It includes various pre-negotiated pricing eye-care services, such as professional eye exams, eyewear, contact lenses and laser vision correction (â€Å"DeltaVision ®Ã¢â‚¬ , n.d.). 8. Delta Dental Member Companies: â€Å"They serve nearly one-third of the estimated 173 million Americans with Dental insurance, providing dental insurance coverage to more than 54 million people in more than 93,000 groups across the nation.†(â€Å"Delta Dental Member Companies†, n.d.). There are other plans which are available in few selected populations and states like the American Association of Retired Persons (AARP) Dental Insurance Plan which is exclusively for AARP members and the Costco Group Dental Plan for the Individuals and Families, which is available only in California (â€Å"Delta Dental’s plans, n.d.). Strengths and weaknesses (especially with healthcare delivery point of view): Delta Dental is the largest dental care carrier in the United States, and they provide coverage to more than 59.5 million people enrolled in more than 97,000 groups. The strengths are obviously regarding to the high level access of the dental care. Many years ago, most of people lost their teeth by middle age, but now many Americans have very good oral health because of the various Delta Dental Plans. They may keep their teeth throughout the lifetime. There are some strengths of Delta Dental according to a recent study (â€Å"Delta Dental by the Numbers†, n.d.): * Delta Dental’s nationwide dentist networks offer unprecedented access: * Delta Dental Premier ® offers the largest network of dentists in the country — encompassing more than 142,000 dentists and more than 251,000 office locations. * Delta Dental PPOSM has a national network of more than 83,900 dentists practicing in more than 168,000 locations. * DeltaCare ® USA provides more than 39,800 dentist office locations. * Delta Dental’s PPO Plan delivers the industry’s best effective discount — averaging 19 percent nationally — resulting in nearly $3 billion in annual savings compared to dentists’ average charges. * Delta Dental posted approximately $17 billion in premium revenue during fiscal year 2011, our 32nd consecutive year of financial gains. * Delta Dental’s unique cost-control measures and contractual agreements with dentists help to ensure quality care at moderate fees, collectively saving subscribers with group dental coverage more than $9.0 billion in 2011. * In 2011, Delta Dental member companies processed more than 90 million dental claims or approximately 1.7 million every week, with an accuracy rate of 99.7 percent. Delta Dental focuses on the practice shari ng, best services, performance guarantees, brand name recognition and reputation, whereas, it still have weaknesses such as geographic limitations, innovative practices. Through the numbers above, people might think that we have more and more dentists in large networks so that we would get easy access to dental care, but how do these dentists located? Low-income patients still feel hard to get access to meet one dentist regularly due to the inconvenient transportation, difficulties on appointments, and so on. The president and CEO of Delta Dental, Radine (2011) wrote on â€Å"Annual Report 2011†, â€Å"Delta Dental takes pride in being a single-line carrier with unparalleled expertise in dental benefits, our specialty.† Indeed, they against larger, multi-line insurance companies, and they use competitive strategies to survive during the worst of the economic downturn. However, this kind of single-line model can also be a weakness of dental health care, because coordination of dentists needed to reinforce to increase the quality of companies health care performance. Single-line service may hinder such coordination in between the large dentist network, although they meet the needs for restraining the continuous increased costs. As each program have dissimilar strengths and weaknesses and according to Access to Dental Care/Oral Health Care (American Dental Association, 2012), there are still barriers to getting oral health care: * The dental sections in Medicaid and the State Children’s Health Insurance Programs (SCHIP), which are supposed to provide health care to disadvantaged Americans, rarely have enough money budgeted to do so. Federal law requires that Medicaid cover basic dental services. But many state programs fail to deliver care to even half of their eligible children. * Adult dental coverage through public health programs is even worse; many states simply don’t provide it. It’s not just about the money. Patients covered under public programs still face hurdles, such as transportation to dental appointments and the difficulty of missing work to keep the appointments. Taking care of ourselves is the key to good oral health, and too many Americans lack a basic understanding of how to brush, floss, eat a healthy diet and drink water with fluoride in it. * About one-third of public water systems are not fluoridated, even though that is the single most effective public health measure to protect against tooth decay. And also, people need to treat what form of coverage they require most and make sure the selected plan provides a low price for the needed processes. Comparison of Delta Dental with all other dental insurances: There are many essential things to keep in mind when deciding on a dental insurance plan, such as prices and co-payment options, local dentist availability, actual coverage, whether it meets your needs and more (â€Å"Dental Insurance Review†, n.d.). Delta Dental Insurance ranking at number three after United Concordia and Ameritas Group Dental is one of the top ten insurance plans in the United States (â€Å"2013 Dental Insurance Comparison†, n.d.). As one of the largest dental coverage plans, founded by dentists, it creates dental coverage plans based on current research and designed to keep people their healthiest and most productive (â€Å"Choosing the Right Dental Plan†, n.d.). Delta Dental Insurance pursues their mission by increasing access to benefits, offering the largest national network of dentists, adding innovative new plan features, aggressively working to keep costs down, and supporting p hilanthropic programs that encourage better overall oral health. Delta Dental Insurance plans offer top of the line features and programs to make insurance services more accessible and convenient for its members. Some of the features that Delta Dental Insurance consists are secure and accessible sites for online enrollment, finding dentists and getting information about available plans. It offers Group/Employer plans, which is important as it gives companies information on the cost of getting dental insurance for their employees. This is important as well for families who wish to enroll other members of the family into the insurance plan. Also Delta Dental Insurance offers individual plans, provides up-front cost information for customers and has Better Business Bureau (BBB) accreditation (â€Å"Dental Insurance Review†, n.d.). Better Business Bureau accreditation is definitely a plus, because they provide ratings based on customer service and satisfaction of members. In addition, Delta Dental Insurance offers multiple types of different plans for its consumers. There is Delta Dental Preferred Provider Organization (PPO), DeltaCare ® USA (Health Maintenance Organization (HMO) option), Fee-for-Service (FFS) Plan, and they also used to offer Discount Plans. But the Discounted Plans are no longer offered by Delta Dental since majority of the members prefer PPO, HMO and FFS plans. The Delta Dental PPO plan is offered worldwide, and for that reason it is more accessible even if the customer relocates (â€Å"Choosing between a PPO and HMO†, n.d.). When choosing a PPO dentist, the out of-pocket costs of customers are often lower because PPO dentists have agreed to charge Delta Dental PPO patients reduced fees. The plan also pays enhanced benefits when patients visit a PPO dentist, so they pay only 20 percent of the PPO dentist’s contracted fee after their deductible for such services as fillings, oral surgery, root canals and treatment of gum disease in addition to other benefit enhancements (â€Å"Types of Dental Plans†, n.d.). Delta Dental PPO does not cover teeth bleaching and other cosmetic procedures (â€Å"University of California†, 2009). The good thing about a PPO plan is that customers have the freedom to choose any licensed dentist, anywhere in the world, each time the member or a family member requires treatment. And there is no referral required for specialty care. On the other hand, DeltaCare ® USA (HMO option) customers must be residents of California to enroll. It provides individuals and their families with inclusive plans and easy referrals to specialists and even has a benefit for teeth bleaching. The plan emphasizes preventive care; so many services are provided at no cost. There is no annual plan maximum for DeltaCare ® USA (â€Å"Types of Dental Plans†, n.d.). As an HMO member, customers are assigned to network dentist that accept the plans and they must be referred specialist by their assigned dentists. Fee-for-service plans, also known as indemnity or traditional plans, typically offer the greatest choice of dentists. It is up to the customer what dentist to choose or procedure they would like to purchase. Like PPO plans, when you visit a network dentist, you typically pay a certain percentage for each service (called coinsurance) and the plan pays the rest. The percentage usually varies by the type of coverage, such as diagnostic and preventive, major services, etc. (â€Å"Types of Dental Plans†, n.d.). However with FFS plan the member might pay a little extra than the PPO plan. And finally, the Discounted Plans are insurance plans that are offered at reduced rates. There is generally no paperwork, annual limits or deductibles, but you must visit a participating dentist to receive the discount. Also, you may be responsible for a greater portion of the treatment cost compare to PPO or HMO plan. The downside of this plan was the fact that there was a possibility of the dentists being changed annually, and new dentists would be assigned to the customers. But on the plus side, the rates that the customers would receive would be unbeatable. Figure 1 shows the continued growth in enrolment throughout the recession. This also proves that Delta Dental is the largest dental carrier in the United States and it has more than 26 million enrollees at present (â€Å"Delta Dental: Annual Report2011†, n.d., p. 10). Figure 1: Shows the increase in the enrollment of Delta Dental plans by the population. The Y-axis shows the number of enrollees in increasing order and the X-axis shows the years starting from 2008-2012. Adapted from: â€Å"Delta Dental: Annual Report 2011.† (n.d., p. 10). Why is Delta Dental better and more successful than other insurances? Delta Dental offers some of the best dental insurance plans in the United States and around the world since 1954 and as the first company exclusively specializing in dental benefits, Delta Dental has been working hard to improve oral health around the world by providing access to the largest network of dentists, great service, top of the line care plans and developing relationships that emphasize prevention and positive oral health care results over the long term (Delta Dental, 2010). Over 56 million enrollees trust Delta Dental Insurance plans with their oral health and the numbers of satisfied members keep growing (â€Å"Why do more than†, n.d.). â€Å"In 2011, the vast majority of surveyed enrollees from our open network plans said they would recommend Delta Dental to a family or friend. That loyalty is also evident in our exceptionally high enrollee retention rate.† (â€Å"Delta Dental 2011 Annual Report†, n.d., p. 11). Figure 2 which is adapted from the â€Å"Delta Dental: Annual Report 2011† (n.d., p. 11) shows the percentage of enrollee satisfaction and enrollee retention in 2011. Figure 2: The percentage of Enrollee satisfaction and Enrollee Retention. 95% of the Enrollees were satisfied with their Delta Dental Plan and 99% of the Enrollees retained their Delta Dental plan. Adapted from: â€Å"Delta Dental: Annual Report 2011† (n.d., p. 11) Delta dental has proven itself as one of the good companies in the market but still they are working diligently to make it better. Delta Dental supports projects in conjunction with major universities and other leading research organizations that are designed to advance scientific knowledge and improve health. Among the projects, recently supports are: a study on the potential for dentists to play a greater role in the detection of health conditions such as diabetes; the cost impact of oral cancer; the application of salivary diagnostics to dentistry; and the development of biotechnology to advance health (Carruth, 2012). All these are the major projects of Delta Dental. Delta Dental is trying to identify ways to improve offerings in ways that will reduce costs while still covering the treatment our subscribers need to stay healthy. Delta Dental will focus on expanding their network in remote places and provide oral care. They are planning continue creating dynamic product lines that provide effective benefits to improve oral health–and overall health – while reducing costs. Delta Dental would concentrate on providing good customer service staff as well as an automated phone line for inquiries. Delta Dental has received many awards in improving oral health care. Their current plans are focused on expanding their network and providing good care for the patients. Delta Dental’s strategies are such that not only patients but also dentist and employees are benefitted. They also focus on many researches to improve quality of care. Moreover, their future plans are focus on reducing cost and providing quality of care for patients. They are providing funds for incurable diseases like cancer and other malignancy. References: A trailblazer in health. n.d.). and your family. r local member companies. Retrieved form: http://www.deltadental.com/Public/PlanInfo/planAddressStart.jsp Delta Dental (n.d.). DeltaVision ®.

Final Report on Stocktrack Portfolio Adjustmnet Essay

Final Report on Stocktrack Portfolio Adjustmnet - Essay Example From the specified figures, it is evident that the final results exceed the expected results, which clear show that the performance of the market was good and so the prospects of investing in the market are positive in terms of maximum benefits and minimal risks. Actually, there is a high probability of the investor benefiting from his investments. Generally, the performance of the portfolio against benchmark index posted an outperformed portfolio. The outperformance can be attributed to improved economy that is just recovering from financial crisis thus enhancing investor’s confidence, vigorous positive public relations by organizations and the market that has played a key role in reducing consumer doubts and promoted their confidence in some organizations such as Goldman Sachs Group, Inc. that were victims of unsubstantiated rumors, and the need by market analysts to set new stock goal that reflects the real financial performance of the organization without the influence of external factors such as investor’s loss of confidence. The first bullish trend was caused by high prospects of economic growth as a result of stimulus package given to companies to protect them from going bankrupt. As a result of the bullish trend, the market underwent correction to reflect the reality of the performance of company in the market. Most of the stock was devalued and so the rate of investment in them went down, but after a while the companies started posting positive results hence stimulating confidence in the market . Adjustment 1, which is based on diversification concept worked better because the rate of return and correlation are independent and so the risk in the portfolio can be minimized without affecting the rate of return. Adjustment 3, which is based on trend analysis, did not work well for my analysis because it only shows the theoretic effects of investor’s demand on the stock. In addition, it does not show

Enterprise Resource Planning Systems Essay Example | Topics and Well Written Essays - 2000 words

Enterprise Resource Planning Systems - Essay Example Although ERP has been the cornerstone of the success stories of most companies from several years, there has not been a unified definition for the term ERP. The absence of a single definition is due to the intrinsic complexity of the motive behind ERP implementation. According to the PC Magazine, "ERP is a concept that aims at utilizing an integrated IT system, which serves all departments within an enterprise" (PC Magazine, 2007). The definition implies that an ERP system is not a custom software, but a packaged software that a company can configure to interface with its own IT systems and business processes (finance, logistics, HR, manufacturing etc). Some of today's leading ERP vendors are SAP, Oracle and Microsoft. Although its implementation has taken various forms, the essential concept of ERP has remained the same. Today ERP has become a worldwide industry standard term for the broad set of activities supported by multi-module application software that helps a manufacturer or other business manage the important parts of its business, including product planning, parts purchasing, maintaining inventories, interacting with suppliers, providing customer service, and tracking orders. ERP can also include application modules for the finance and human resources aspects of a business (EC Council, 2002). ERP is a standaERP Customization: The First Step to Success ERP is a standard software package, and like any other standard software package aimed at automating an anonymous industry; it must be tailored to the specific requirements of the business domain in which it is being used. According to Gartner Group (1997), the scale of Business Process Re-Engineering and customization account for the maximum reasons for ERP implementation failures. Therefore customization of the ERP software is a primary and a critical step in ERP implementation. Two types of tailoring methods can be applied to customize the ERP software to the specific business. Customize the ERP package to suit the business process. Business Process Re-Engineering: Customizing the Business Process to suit the ERP package. In the first scenario, the company buys the off-shelf ERP package, and customizes the software based on the business rules and policies defined by the company. The second scenario is the one that is most commonly applied. In this customization strategy, the company re-engineers its business processes to match the vendor's ERP logic. It is not essential that all the business processes of the company be re-engineered. The company performs BPR on only those business processes that are currently not in tandem with the philosophy of the ERP package. ERP implementation and BPR activities should be closely connected. ERP implementation should involve the analysis of current business processes and the chance of reengineering, rather than designing an application system that makes only the best of bad processes (Scheer & Habermann, 2000). Current ERP Technology Most current ERP software packages are based on 3-Tier Client Server Architecture. The 3 tiers of this architecture are: User Interface: Contains the GUI that receives user input. Business Logic: These are servers

The Economy of Israel :: Israeli Palestinian Economies Economics Essays

What the parties will gain: the economic aspect of the agreement. The second redeployment agreement can serve as a springboard for both the Israeli and Palestinian economies, separately and together. The greater beneficiaries, politically, economically and propaganda-wise, are the Palestinians. The agreement removes restrictions and solves hardships that have prevented growth and development in the Palestinian Authority. The influence of the Israeli economy has been lessened and will be expressed mainly in the change of atmosphere. In the coming months, the three countries -- Israel, Jordan and the Palestinian Authority -- will be considered by the international business community to be more stable and less dangerous and thus more attractive for investment. If investments arrive is another matter, depending on the global economic situation. President Clinton has promised Israel "security aid," but no economic aid, to implement the agreement. The amount of the special aid will reach hundred of millions of dollars, Jerusalem believes. The expense must be approved by Congress. Will the second redeployment agreement have the power and spirit to pull the Israeli economy out of its recession and calm the foreign currency market? Doubtful. Much more is needed to do that -- an economic policy devoted to growth, a comprehensive Israeli-Palestinian-Arab peace, as well as a renewal of the concept of a "New Middle East Economy." What are the economic advantages for the Palestinians from the second redeployment agreement? In a sentence, they will be less dependent on Israel and will stand more firmly on their own feet. * An international airport in Gaza will serve tourists, visitors and Palestinian importers and exporters, without Israeli intervention. * Safe passage between the two parts of the PA will, over time, enable the free flow of work, capital and initiative. * Industrial zones -- the first at the Karni crossing -- will promote Palestinian high- tech, which is just starting out. Investors may come. * A port at Gaza, though not economically viable, will give a feeling of independence and remove the economic stranglehold that the Palestinians complain about. Construction work on the port will provide employment for many Palestinians. * A presidential visit by Bill Clinton in Gaza will be an important signal to the American business community to invest with the Palestinians; the president usually brings plenty of businessmen to such shows of friendship. * The United States will supply the Palestinian Authority with additional economic aid, totaling hundreds of millions of dollars.

Airasia: Low Cost Carriers in Asia Pacific Essay

The use of information technology plays an important role in the strategic and operation management of airlines,and facilitates the successful airlines in the future. This paper will look at the awarding-winning low cost carriers (LCC) in Asia Pacific region – AirAsia, analyzes the current business environment, competitive advantages, value chain, current implementation of information technology, and the recommended future implementation of technology in customer relationship management (CRM) implementation to pursue competitive differentiation and profitability effectively in the future. COMPANY BACKGROUND AirAsia is one of the award winning and largest low fare airlines in the Asia expanding rapidly since 2001. With a fleet of 72 aircrafts, AirAsia flies to over 61 domestic and international destinations with 108 routes, and operates over 400 flights daily from hubs located in Malaysia, Thailand, and Indonesia. Today, AirAsia has flown over 55 million guests across the region and continues to create more extensive route network through its associate companies. AirAsia believes in the no-frills, hassle-free, low fare business concept and feels that keeping costs low requires high efficiency in every part of the business. Through the corporate philosophy of â€Å"Now Everyone Can Fly†, AirAsia has sparked a revolution in air travel with more and more people around the region choosing AirAsia as their preferred choice of transport. AirAsia creates values through the following vision and mission: Vision Mission To be the largest low cost airline in Asia and serving the 3 billion people who are currently underserved with poor connectivity and high fares.To be the best company to work for whereby employees are treated as part of a big family Create a globally recognized ASEAN brand To attain the lowest cost so that everyone can fly with AirAsia Maintain the highest quality product, embracing technology to reduce cost and enhance service levels AirAsia makes the low fare model possible and create values through the implementation of the following key strategies: Strategies Safety First Partnering with the world’s most renowned maintenance providers and complying with the world airline operations. High Aircraft Utilization Implementing the regions fastest turnaround time at only 25 minutes, assuring lower costs and higher productivity. Low Fare, No Frills Providing guests with the choice of customizing services without compromising on quality and services. Streamline Operations Making sure that processes are as simple as possible. Lean Distribution System Offering a wide and innovative range of distribution channels to make booking and travelling easier. Point to Point Network Applying the point-to-point network keeps operation simple and lower costs.

Theme Of Human Frailty In Sir Gawain And The Green Knight

Both human honor and human frailty are prevalent throughout the vast works of medieval literature. There is an undeniable pattern amongst such works that presents a heroic code of honor, but also exposes the trickery or deceit some have selfishly fallen victim to. Whether it is a boastful display of courage and bravery, or a shameful episode of cowardice and temptation, the characters of Anglo-Saxon literature demonstrate both the best and the worst of each. In this essay, I will use the poems â€Å"The Wanderer†, Beowulf, and Sir Gawain and the Green Knight to exemplify this point. Most of the human honor presented in these poems comes from the portrayal of a hero. A hero in Anglo-Saxon culture not only had to be tough, courageous and†¦show more content†¦Grendel’s killing of the men in there sleep shows moral weakness and frailty on his part. The men are defenseless, so it is an unfair fight that further promotes Beowulf’s honorability. Similarly to t he wanderer, Beowulf also keeps his word and never complains, regardless of how difficult or dangerous a task seemed. This proves to be one of the key traits of an honorable Anglo-Saxon hero. Wiglaf also demonstrates honor and human goodness when he refuses to back out of the battle. He says, â€Å"A warrior will sooner / die than live a life of shame† (2890-2891). Wiglaf would rather keep his honor and lose his life, than live a life of shame because of cowardice. On the other hand, more human frailty can be identified in the poem Sir Gawain and the Green Knight. By definition, human frailty is moral weakness or an inability to avoid temptation. Initially Gawain appears to be nothing short of honorable and prestigious; however, towards the end of the story readers are shown his more frail side, one of promiscuity and temptation. As on of King Arthur’s most valuable knights, Gawain is commonly known for his loyalty to his king and his courage to face any challenge in his knightly duties. Like Beowulf, he will face any danger no matter the risk. He demonstrates the best of his human honor when he volunteers himself into the game rather than letting King Arthur risk his own life. He says, â€Å"I beseech, before all here, that this melee may be mine.† His courage and loyaltyShow MoreRelated Gawains Encounter with the Green Knight in the Green Chapel1577 Words   |  7 PagesGawains Encounter with the Green Knight in the Green Chape l Even though little is known about the author of Sir Gawain and the Green Knight, it is considered to be one of the greatest romances of all time. The poem tells the story of one of Arthurs noblest and most courageous knights, Sir Gawain, who is in search of the Green Chapel: Sir Gawain ingeniously combines two plots, common in folklore and romance, although not found together elsewhere: the beheading contest, in which two parties