A System of Integrated Care for Older Persons With Disabilities in Canada:Results From a Randomized Controlled Trial
Franc?ois Be′land,1,2,3Howard Bergman,1,2,3Paule Lebel,4A.Mark Clar?eld,3,5 Pierre Tousignant,6Andre′-Pierre Contandriopoulos,2and Luc Dallaire1
1Solidage Research Group,Montre′al,Que′bec,Canada.
2Department of Health Administration,Universite′de Montre′al,Que′bec,Canada.
3Division of Geriatric Medicine,McGill University,Jewish General Hospital,Montreal,Que′bec,Canada.
4Institut Universitaire de Ge′riatrie de Montre′al,Que′bec,Canada.
5Division of Geriatric Medicine,Soroka Hospital and Ben Gurion University,Beer Sheva,Israel.
6Department of Epidemiology and Biostatistics,McGill University,Montre′al,Que′bec,Canada.
Background.Care for elderly persons with disabilities is usually characterized by fragmentation,often leading to more intrusive and expensive forms of care such as hospitalization and institutionalization.There has been increasing interest in the ability of integrated models to improve health,satisfaction,and service utilization outcomes.
Methods.A program of integrated care for vulnerable community-dwelling elderly persons(SIPA[French acronym for System of Integrated Care for Older Persons])was compared to usual care with a randomized control trial.SIPA offered community-based care with local agencies responsible for the full range and coordination of community and institutional (acute and long-term)health and social services.Primary outcomes were utilization and public costs of institutional and community care.Secondary outcomes included health status,satisfaction with care,caregiver burden,and out-of-pocket expenses.
Results.Accessibility was increased for health and social home care with increased intensi?cation of home health care. There was a50%reduction in hospital alternate level inpatient stays(‘‘bed blockers’’)but no signi?cant differences in utilization and costs of emergency department,hospital acute inpatient,and nursing home stays.For all study participants, average community costs per person were C$3390higher in the SIPA group but institutional costs were C$3770lower with,as hypothesized,no difference in total overall costs per person in the two groups.Satisfaction was increased for SIPA caregivers with no increase in caregiver burden or out-of-pocket costs.As expected,there was no difference in health outcomes.
Conclusions.Integrated systems appear to be feasible and have the potential to reduce hospital and nursing home utilization without increasing costs.
D EVELOPED countries face the challenge of ef?ciently
meeting the needs of a growing vulnerable elderly population.Those persons with signi?cant functional dis-abilities are typically older than75years,suffer from com-plex acute and chronic medical problems,and often have overextended social support(1,2).Comprising approxi-mately20%of the older population(3,4),they utilize a disproportionate amount of both acute hospital and nursing home(NH)care with frequent transitions between them(5). Care for frail elderly persons is characterized by fragmentation and weak accountability(6,7)leading to higher levels of hospital and NH utilization(8,9).There has been increasing interest in the ability of integrated systems to improve health,satisfaction,and utilization outcomes (10–13).Yet there have been few published studies with control groups utilizing either a randomized controlled trial (RCT)or quasi experimental methodology.
We conducted an RCT designed to assess a transformation of the organization and delivery of health and social services with intensi?ed community-based interventions for frail elderly persons.We hypothesized that this model would change service con?guration by decreasing hospital and NH stays.(In Canada,NH signi?es long-term institutional care). The intervention was not designed to reduce costs but to demonstrate that the transformation of the service con?g-uration(increasing community intervention with decreased reliance on the hospital and NH)could be achieved and be cost neutral.Increased satisfaction with care without increased burden or out-of-pocket costs was expected.We did not hypothesize clinically signi?cant differences in health status because of the patients’compromised health status and the short intervention period.
M ETHODS
Intervention and Study Sites
The SIPA(French acronym for System of Integrated Care for Older Persons)program has been described previ-ously(8).Its distinguishing features are community-based multidisciplinary teams with full clinical responsibility for delivering integrated care through the provision of commu-nity health and social services and the coordination of
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hospital and NH care;all within a publicly managed and funded system.
The SIPA project was carried out in two Montre′al CLSCs,public community organizations responsible for home care in the province of Que′bec(14).Although SIPA teams were based in the CLSCs,they were distinct,with their own budget,personnel,and governance.Each of the two teams(Table1)per site was responsible for160 patients,assessing their needs and organizing and delivering most community services.With the objective of integrating care,a comprehensive geriatric assessment was carried out on admission to SIPA.A series of evidence-based interdisciplinary protocols(nutrition,falls,congestive heart failure,dementia,depression,medication,vaccination)were developed and applied in collaboration with the patient’s family physician.With the aim of rapidly meeting needs and avoiding inappropriate hospital and NH utilization,the teams readily mobilized resources,including intensive home care,group homes,and a24-hour on-call service.Case managers intervened on medical and social issues with patients and caregivers,liaised with family physicians,and actively followed patients throughout the care trajectory, assuring continuity and easing transitions between hospital and community.
Patients were encouraged to continue to see their own physician.The606SIPA patients were distributed among 245family physicians with each physician caring for between1and10patients.In addition to their usual fee-for-service payments,the sites offered the family physicians $400per SIPA patient annually to compensate for their time communicating with the team.With limited availabil-ity,the SIPA staff physicians followed a small number of participants and served as backup and resource to the team and family physician.
Agreements concerning service provision were negoti-ated with other providers,particularly hospitals.The SIPA teams maintained clinical responsibility and accountability for utilization,in hospitals as well as in the community,and monitored the application of protocols.They also con-trolled their own budgets,allowing intensive and?exible utilization of home services,group homes,and additional services.In a subsequent phase of the project the goal was to move toward full?nancial responsibility with a per capita budget.
The controls were offered the usual CLSC home care services including nursing,rehabilitation,physician,per-sonal,and social services but with limited time and availability,and essentially no case management.The home care services had little control over the budget,and could not pay for attendance in group homes.There was no responsibility for clinical or utilization outcomes except for CLSC-provided services.
Design and Participants
The evaluation was designed as an RCT over a22-month period(June1999to March2001).Eligibility criteria were: being older than64years,community-dwelling,residing within the two CLSC territories,being competent in French or English(either the participant or caregiver),and having a participating caregiver(if a caregiver existed).Disability was assessed with the Functional Autonomy Measurement System(SMAF)scale(15)which includes activities of daily living(ADL),instrumental ADL(IADL),communication, and cognition.Only those persons with at least moderate disability(score ofà10or less)were eligible.Those persons with a pending NH admission or move out of CLSC territory were excluded.
The total sample size of1270was calculated(a?0.05 and b?0.90)to detect hospital and NH outcome differences (admissions,utilization,and costs)of25%and50%, respectively,based on a previous study of resource use in frail elderly persons,and taking into consideration expected attrition rates(16).In fact,1230elderly persons received their allocated intervention(Figure1).
Participants were recruited mainly from CLSC commu-nity programs,with a small proportion from other sources. Informed consent was obtained from patients(or proxies) and caregivers.Participants were randomly allocated to either SIPA or control according to the allocation sequence (block size of6–8)generated by the SAS Plan procedure (17).The research ethics committees of the Jewish General Hospital and the two CLSCs approved the protocol.The intention-to-treat principle was applied.The average length of enrollment was572days over the669-day trial;57.1%of the participants were enrolled for the whole period. Primary outcomes were differences between SIPA and control for admissions,service utilization(total hours or days over the study period)and public costs of inpatient acute care, alternate level of care(ALC;patients who,following their acute hospital episode,remain in hospital awaiting NH placement,otherwise known as‘‘bed-blockers’’),NH,home health,and social care.Total institutional and community costs(whose components are shown in Table2),and overall total costs were also compared.Secondary outcomes in-cluded health status,satisfaction with care,out-of-pocket expenses,and caregiver burden for the?rst12-month period. Data
Utilization and cost data were obtained from provincial government,regional health board,and CLSC databases. Additional data were manually extracted from hospital, CLSC,NH,and rehabilitation center patient records by trained assistants blinded to the participants’trial status. Socioeconomic,demographic,health status,satisfaction with care,and out-of-pocket expense data(Table3)were collected during home interviews.Questionnaires were administered to study participants by trained interviewers
Table1.Multidisciplinary Team Composition
4Case managers(nurse or social worker)
2Community nurses
0.5Social workers
0.5Occupational therapists
0.5Physiotherapists
15Homemakers
0.5Staff family physicians
0.5Consultant pharmacists(1site only)
0.2Community organizers(1site only)
368BE′LAND ET AL.
at baseline(t0)and1year later(t1);caregivers were interviewed only at t1.Interviewers were blinded to the experimental status of the interviewees.
Statistical Analysis
Differences between SIPA and control groups were tested using multivariate response models.These models allow for
correlated dependent variables,which is necessary as admission to services,and utilization and costs of the different care components may be highly correlated with each other.
Admissions to services were entered as dependent var-iables in the models along with utilization,or costs.Statistical tests for these analyses were run on users only as the high proportions of non-users of some services may drive the comparisons of utilization and costs.All cost and utilization variables were log-transformed as they were skewed.The regression coef?cients for experimental effects on utilization and costs can therefore be interpreted as percentages of change due to SIPA(26).Data on the deceased were included in the analysis of utilization and costs of services up to their death.Costs are reported in Canadian dollars.
Changes between t0and t1in out-of-pocket expenses and participants’satisfaction were compared in the SIPA and control groups using a repeated-measures procedure which allowed use of all data at both time points(27).Caregivers’burden and satisfaction were compared at t1only.
In all of the analyses,socioeconomic characteristics, health indicators,and study site were controlled for. Supplemental cost analyses were performed to assess the impact of SIPA for subgroups,testing for interactions of trial status(SIPA or control)with socioeconomic character-istics and health status.
R ESULTS
The control and SIPA groups did not differ signi?cantly on socioeconomic characteristics or health status at baseline (Table4).SIPA had no effect on change of health status or mortality,as expected.
Multivariate analyses showed that signi?cantly more SIPA participants compared to controls received both home health and home social care(Table5).SIPA participants who received home health care also had62%more hours of care at64%greater cost than did the controls receiving home health care.There was no difference in hours or costs of home social care.
There was also a highly signi?cant50%reduction in the number of acute hospital patients in the SIPA group that became ALC(Table5).After transfer to ALC,there were no signi?cant differences in utilization or costs,although there was a trend for SIPA participants to have longer stays.
https://www.doczj.com/doc/655377288.html,ponents of Institutional and Community Care Institutional Care Community Care Emergency department(ED)Home health care
Inpatient acute care Nursing
Alternate level of care(ALC)Physical therapy
Nursing home(NH)Occupational therapy
Day hospital Nutritional services Inpatient rehabilitation Home social care
Palliative care Homemaking
Ambulance transportation Social work
Psychosocial services
Geriatric day hospital and centers
Technical aids
Physician visits
Prescribed drugs
Group homes
Table3.Content of Patient and Caregiver Questionnaires
Variable Measurement (Instrument)
Study Participants(t0and t1)
Age Continuous variable
Education Six achievement levels
Income5-point scale of subjective
suf?ciency of household income Self-declared chronic diseases EPESE scale(18)
Depression GDS(19)
Cognition SPMSQ(20)
Functional limitations Nagi scale(21)
Instrumental Activities of
Daily Living(IADL)
OARS(22)
Activities of Daily Living(ADL)Items from the Barthel scale(23) Client satisfaction CSQ-8(24)
Out-of-pocket expenses(*)Self-report previous2weeks Caregivers(t1only)
Caregiver satisfaction CSQ-8
Caregiver burden Zarit scale(25)
Notes:*Out-of-pocket expenses included nursing,homemaker,over-the-counter medication,technical aids,and transport to access health and social services.
EPESE?Established Populations Epidemiologic Study of the Elderly;GDS ?Geriatric Depression Scale;SPMSQ?Short Portable Mental State Questionnaire;OARS?Older Americans Resources and Services;CSQ-8?Client Satisfaction Questionnaire-8.
Table4.Baseline Status of Trial Participants
Baseline Characteristic
Control
Average
or%
SIPA
Average
or%p Value Age,years(range64–104)8282.52 Sex,%males28%29%.61 Education,%high school and over70%68%.61 Income suf?ciency,%with suf?cient
income34%35%.70 Live alone,%40%44%.20 No.of chronic diseases(range0–16) 5.0 4.9.49 Functional limitations:No.performed
with dif?culty 3.3 4.0.07 ADL disabilities:No.not performed
or with help 3.1 3.1.70 IADL disabilities:No.not performed
or with help 4.4 4.4.95 Incontinence,%46%41%.12 Cognitive problems,%with3ton SPMSQ32%31%.59 Depressive symptoms,%with10ton GDS14%12%.41 Perceived health,%with good to excellent51%53%.51 Note:SIPA?French acronym for System of Integrated Care for Older Persons;ADL?activities of daily living;IADL?Instrumental Activities of Daily Living;SPMSQ?Short Portable Mental Health Status;GDS?Geriatric Depression Scale.
370BE′LAND ET AL.
There were no signi?cant differences in admissions,utilization,or costs for the other components of institutional care:emergency department (ED),acute hospital,and NH.For ED,there was a trend for 10%lower utilization and costs for SIPA,but this did not reach signi?cance.In the multivariate analysis,total community costs were 44%higher for SIPA compared to control group users,whereas total institutional costs were 22%lower.The increase in mean community costs per study participant in the SIPA group ($3,390)was compensated by a decrease in mean institutional costs ($3,770)(Figure 2).Overall SIPA was cost neutral.There was an insigni?cant increase in satisfaction for SIPA participants over 12months.Caregivers’satisfaction
after 1year was signi?cantly higher for SIPA than for controls.There were no differences in caregiver burden or out-of-pocket costs.Supplemental Analyses Four interaction terms for trial group status with socioeconomic and health status proved signi?cant.The costs of home health care for SIPA compared with control users increased with the number of chronic diseases,and cost savings for NH were greatest ($9,600)for those patients with fewer than four chronic diseases.NH costs for SIPA users living alone were $14,500less than for similar controls.Finally,compared to those for controls,costs of acute care hospitalizations were $4,000less for SIPA participants with low levels of ADL disability and more than $5,000lower for those participants with moderate to severe ADL disability.
D ISCUSSION
This is the ?rst North American RCT of an integrated system for disabled elderly persons.This trial followed the CONSORT guidelines (28)and is,to our knowledge,the largest of its kind with the longest experimentation period (22months).Results indicate that SIPA,although cost neutral,succeeded in changing the con?guration of care with a reduction in the overall acute hospital and NH utilization associated with a concomitant increase in community care.The reduction in ALC and the pattern of reduction in acute hospitalizations and in NH costs suggest that SIPA’s most important impact was in reducing hospital utilization for those participants with increased ADL disability,reducing use of the hospital as a ‘‘conduit’’for NH placement,while apparently delaying NH placement for Table 5.Effects of SIPA on Care Accessed,Utilization and Costs y
Type of Care
Care Accessed
Utilization z Costs of Care z Odds Ratio (95%CI)%Increase (95%CI)%Increase (95%CI)Home health care
1.72*(1.20,
2.46)62%*(46,79)64%*(46,83)Home social care
2.16*(1.60,2.91)à17%(à45,10)à22%(à50,7)Inpatient care
0.93(0.71,1.18)à5%(à21,11)à5%(à23,13)ED visits
0.92(0.73,1.20)à11%(à24,2)à10%(à26,7)Alternate level
of care
0.52*(0.33,0.82)37%(à4,78)17%(à28,71)Skilled nursing
homes 1.09(0.78,1.52)11%(à14,42)
3%(à24,47)Note :*Signi?cant at the .05level.
y In all models,socioeconomic characteristics,health status,and site were controlled.
z Utilization and costs are for service users only.Dependent variables were log-transformed for a better ?t with the normal distribution.
SIPA ?French acronym for System of Integrated Care for Older Persons;CI ?con?dence interval;ED ?emergency
department.Figure 2.Average costs per study participant of total community and institutional services.
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AN RCT OF INTEGRATED CARE FOR ELDERS
those with few chronic diseases(lesser risk)and for those living alone(higher risk).
These results are relevant in many jurisdictions(29,30). In Canada,patients who cannot return home remain in hospital waiting for a place in a NH.This problem of ALC patients is particularly important in Montreal,where a recent government document(31)identi?ed‘‘bed-blockers’’and long acute hospital stays of older persons as a threat to hospital and ED accessibility.It has also been demon-strated that caring for‘‘bed-blockers’’in an acute hospital is signi?cantly more costly than caring for the same persons in a NH(32).SIPA therefore has important implications in helping to preserve access to acute hospital specialist functions.
The trial results are likely explained by several factors. Case managers spent a signi?cant amount of time dealing with issues of hospitalization and discharge.They were able to ef?ciently mobilize additional professional,homemaker, and group home resources.Timely follow-up,together with the ability to problem solve,instilled con?dence in hospital professionals and caregivers that discharge to the commu-nity would be safe and successful.
Several factors explain the inability of the intervention to demonstrate signi?cant reductions in hospital days,ED visits,and NH utilization.Poor incentives for family physician engagement in the care of frail elderly persons, a problem being addressed in Canadian policy statements, limited their involvement and the SIPA teams’ability to mobilize timely community medical intervention(33).Also, the number of study patients per family physician(1–10)was too small for SIPA to have much impact on their practice. Although SIPA staff received preparatory training,there was no lead time before the evaluation began to allow staff to adapt to the signi?cant paradigm change that the SIPA model represents.Uncertainty about funding beyond12months resulted in certain key staff leaving the project.Per capita funding was not implemented as planned as it proved too complex within the Canadian health system,where global budgets are usual.It was therefore not possible to implement ?nancial accountability,limiting incentives to reduce in-appropriate utilization.Although SIPA and control teams were distinct,they did work in the same agency and building, so contamination and emulation are possible factors. Concurrent with the trial there were also signi?cant increases in the home care budget in Montreal,including that of the control group.The study was powered to test for large differences of between25%and50%,and this may explain our inability to demonstrate statistical signi?cance for some of the trends observed.Arguably even a10%difference in the utilization and costs of services is clinically and?nancially meaningful,particularly for acute hospitalization.
Our results are consistent with those reported for similar models developed in the United States.Although the results of Social/Health Maintenance Organization trials were disappointing(34),the Program of All-Inclusive Care for the Elderly(PACE)attracted considerable interest,and is now a Medicare provider.Although not evaluated with an RCT or quasi experimental methodology,PACE does appear to reduce hospitalization and institutionalization with no increase,and possibly a reduction,in costs in comparison with the general Medicare population(35–37). Two smaller Italian studies,one of which was an RCT, reported similar reductions in hospitalizations and costs (38,39).
Our study indicates the feasibility of rigorously assessing a major change in the delivery and organization of care for disabled older persons.In spite of some limitations,this trial and others point to the potential for integrated systems to reduce acute hospital and NH utilization without increasing costs or caregiver burden,while increasing satisfaction among caregivers.
A CKNOWLEDGMENTS
Franc?ois Be′land and Howard Bergman contributed equally to the article. This work was supported by the Health Transition Fund(Health Canada);Canadian Institutes of Health Research;Canadian Health Services Research Foundation;Fonds de la recherche en sante′du Que′bec(FRSQ); Quebec Ministry of Health and Social Services.
We are indebted to Silvia Hummel,MSc,for assistance in the preparation of the manuscript;John Fletcher,MSc for assistance in carrying out data analysis;Kathy Lesperance,MSc,and Christian Morales,MSc,for assistance in preparation of the questionnaire and the evaluation of the utilization and costs;Ce′line Bureau for her advice;Jean Franc?ois Boivin, MD,ScD,Stan Shapiro,PhD,and David Hogan,MD,for their advice on the methodology and their critical reading of the manuscript;Elizabeth Iacono and Karine Dumont for secretarial assistance.
Research was carried out at the Solidage:McGill University/Universite′de Montre′al Research Group,Center for Clinical Epidemiology and Community Studies,Lady Davis Institute for Medical Research,Jewish General Hospital,McGill University.
Address correspondence to Howard Bergman,MD,Division of Geriatric Medicine,McGill University,3755Cote-Ste-Catherine,Montreal,QC H3T 1E2Canada.E-mail:howard.bergman@mcgill.ca
R EFERENCES
1.The Canadian Study of Health and Aging Working Group.Disability
and frailty among elderly Canadians:a comparison of six surveys.Int Psychogeriatr.2001;13Supp1:159–167.
2.Wolff JL,Star?eld B,Anderson G.Prevalence,expenditures,and
complications of multiple chronic conditions in the elderly.Arch Intern Med.2002;162:2269–2276.
3.Fried LP,Walston J.Frailty and failure to thrive.In:Hazzard WR,
Blass JP,Halter JB,Ouslander JG,Tinetti ME,eds.Principles of Geriatric Medicine and Gerontology,5th ed.New York:McGraw Hill;
2003:1487–1502.
4.Freedman VA,Martin LG,Schoeni RF.Recent trends in disability and
functioning among older adults in the United States:a systematic review.JAMA.2002;288:3137–3146.
5.Murtaugh CM,Litke A.Transitions through postacute and long-term
settings:patterns of use and outcomes for a national cohort of elders.
Med Care.2002;40:227–236.
6.Callahan EH,Thomas DC,Goldhirsch SL,Leipzig RM.Geriatric
hospital medicine.Med Clin North Am.2002;86:707–729.
7.Black D,Bowman https://www.doczj.com/doc/655377288.html,munity institutional care for frail elderly
people.BMJ.1997;315:441–442.
8.Bergman H,Beland F,Lebel P,et al.Care for Canada’s frail elderly
population:fragmentation or integration?CMAJ.1997;157:1116–1121.
9.Coleman EA.Challenges of systems of care for frail older persons:the
United States of America experience.Aging Clin Exp Res.2002;14: 233–238.
10.Bodenheimer T.Long-term care for frail elderly people—the On Lok
model.N Engl J Med.1999;34:1324–1328.
11.Johri M,Be′land F,Bergman H.International experiments in integrated
care for the elderly:a synthesis of the evidence.Int J Geriatr Psychiatry.2003;18:222–235.
372BE′LAND ET AL.
12.Boult C,Pascala JT.Integrating healthcare for older populations.Am J
Manag Care.1999;5:45–52.
13.Kane RL.Managed care as a vehicle for delivering more effective
chronic care for older persons.J Am Geriatr Soc.1998;46:1034–1039.
14.Trahan L.Caris P.The system of care and services for frail older
person in Canada and Quebec.Aging Clin Exp Res.2002;14: 226–232.
15.He′bert R,Carrier R,Bilodeau A.The Functional Autonomy
Measurement System(SMAF):description and validation of an instrument for the measurement of handicaps.Age Ageing.1988;17: 293–302.
16.Be′land F,Haldemann V,Martin JC,et al.Vieillir dans la communaute′:
sante′et autonomie,rapport de recherche PNRDS#6605-4570-602, Montre′al,30mai1998.
17.SAS Institute Inc.SAS/STAT User’s Guide,version6,4th ed.Volume
2.Cary,NC:SAS Institute Inc.;1989:1221–1240.
18.Cornoni-Huntley J,Ostfeld AM,Taylor JO,et al.Established
populations for epidemiologic studies of the elderly:study design and methodology.Aging(Milano).1993;5:27–37.
19.Yesavage JA,Brink TL,Rose TL,et al.Development and validation of
a geriatric depression screening scale:a preliminary report.J Psychiatr
Res.1982;17:37–49.
20.Pfeiffer E.A short portable mental status questionnaire for the as-
sessment of organic brain de?cit in elderly patients.J Am Geriatr Soc.
1975;23:433–441.
21.Nagi SZ.An epidemiology of disability among adults in the United
https://www.doczj.com/doc/655377288.html,bank Mem Fund Q Health Soc.1976;54:439–467.
22.Fillenbaum GG,Smyer MA.The development,validity,and reliability,
of the OARS multidimensional functional assessment questionnaire.
J Gerontol.1981;36:428–434.
23.Mahoney FI,Barthel DW.Functional evaluation:the Barthel Index.
Md State Med J.1965;14:61–65.
24.Attkisson CC,Green?eld TK.The client satisfaction questionnaire
(CSQ)Scales:a history of scale development and guide for users.
Department of Psychiatry,University of California.San Francisco, CA:University of California;1995.
25.Zarit SH,Reever KE,Bach-Peterson J.Relatives of the impaired elderly:
correlates of feelings of burden.Gerontologist.1980;20:649–655. 26.Greene WH.Econometric Analysis.Upper Saddle River,NJ:Prentice
Hall;2003.
27.Goldstein H.Multilevel Statistical Models,2nd ed.New York:Halstead
Press;1995.
28.Moher D,Schulz KF,Altman DG.The CONSORT statement:revised
recommendations for improving the quality of reports of parallel-group randomized https://www.doczj.com/doc/655377288.html,ncet.2001;357:1191–1194.29.Department of Health(2000)Shaping the future NHS:long term
planning for hospitals and related services.Available at http://www.
https://www.doczj.com/doc/655377288.html,/assetRoot/04/02/04/69/https://www.doczj.com/doc/655377288.html,st accessed August 16,2005.
30.Brodsky J,Habib J,Hirschfeld M,Siegal B.Care of the frail elderly in
developed and developing countries:the experience and the challenges.
Aging Clin Exp Res.2002;14:279–286.
31.Re′gie re′gionale de la sante′et des services sociaux de Montre′al-Centre.
Le plan montre′alais d’ame′lioration de la sante′et du bien-e?tre2003–2006,?la sante′en actions?.Bibliothe`que nationale du Que′bec,2003, ISBN2-89510-134-5.Available at http://www.santemontreal.
qc.ca/pdf/documentations/pubs/santeactionsplan2003-06.pdf Last ac-cessed August16,2005.
32.Friedman R,Kalant https://www.doczj.com/doc/655377288.html,parison of long-term care in an acute care
institution and in a long-term care institution.CMAJ.1998;159: 1107–1113.
33.Canadian Health Services Research Foundation.The path for re-
structuring primary healthcare services in Canada.CHSRF2003.
Available at http://www.chsrf.ca/?nal_research/commissioned_research/ policy_synthesis/pdf/choices_for_change_https://www.doczj.com/doc/655377288.html,st accessed August 16,2005.
34.Kane RL,Kane RA,Finch M,et al.S/HMOs,the second generation:
building on the experience of the?rst social health maintenance organization demonstrations.J Am Geriatr Soc.1997;45:101–107. 35.Chatterji P,Burstein NR,Kidder D,White A.Evaluation of the
Program of All-inclusive Care for the Elderly(PACE)demonstration: the impact of PACE on participant outcomes.Cambridge,MA:Abt Associates Inc.;1998:1–60.
36.White AJ,Abel Y,Kidder D.Evaluation of the Program of All-
inclusive Care for the Elderly demonstration.A comparison of the PACE capitation rates to projected costs in the?rst year of enrolment.
Cambridge,MA:Abt Associates Inc.;2000.
37.Wieland D,Lamb VL,Sutton SR,et al.Hospitalization in the Program
of All-Inclusive Care for the Elderly(PACE):rates,concomitants,and predictors.J Am Geriatr Soc.2000;48:1373–1380.
38.Bernabei R,Landi F,Gambassi G,et al.Randomized trial of impact of
model of integrated care and case management for older people lining in the community.BMJ.1998;316:1348–1351.
https://www.doczj.com/doc/655377288.html,ndi F,Gambassi G,Pola R,et al.Impact of integrated home care
services on hospital use.J Am Geriatr Soc.1999;47:1430–1434. Received October13,2004
Accepted December3,2004
Decision Editor:John E.Morley,MB,BCh
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AN RCT OF INTEGRATED CARE FOR ELDERS
How to manage time Time treats everyone fairly that we all have 24 hours per day. Some of us are capable to make good use of time while some find it hard to do so. Knowing how to manage them is essential in our life. Take myself as an example. When I was still a senior high student, I was fully occupied with my studies. Therefore, I hardly had spare time to have fun or develop my hobbies. But things were changed after I entered university. I got more free time than ever before. But ironically, I found it difficult to adjust this kind of brand-new school life and there was no such thing called time management on my mind. It was not until the second year that I realized I had wasted my whole year doing nothing. I could have taken up a Spanish course. I could have read ten books about the stories of successful people. I could have applied for a part-time job to earn some working experiences. B ut I didn’t spend my time on any of them. I felt guilty whenever I looked back to the moments that I just sat around doing nothing. It’s said that better late than never. At least I had the consciousness that I should stop wasting my time. Making up my mind is the first step for me to learn to manage my time. Next, I wrote a timetable, setting some targets that I had to finish each day. For instance, on Monday, I must read two pieces of news and review all the lessons that I have learnt on that day. By the way, the daily plan that I made was flexible. If there’s something unexpected that I had to finish first, I would reduce the time for resting or delay my target to the next day. Also, I would try to achieve those targets ahead of time that I planed so that I could reserve some more time to relax or do something out of my plan. At the beginning, it’s kind of difficult to s tick to the plan. But as time went by, having a plan for time in advance became a part of my life. At the same time, I gradually became a well-organized person. Now I’ve grasped the time management skill and I’m able to use my time efficiently.
英语演讲稿：未来的工作 这篇《英语演讲稿范文：未来的工作》，是特地，希望对大家有所帮助！ 热门演讲推荐：竞聘演讲稿 | 国旗下演讲稿 | 英语演讲稿 | 师德师风演讲稿 | 年会主持词 | 领导致辞 everybody good afternoon:. first of all thank the teacher gave me a story in my own future ideal job. everyone has a dream job. my dream is to bee a boss, own a pany. in order to achieve my dreams, i need to find a good job, to accumulate some experience and wealth, it is the necessary things of course, in the school good achievement and rich knowledge is also very important. good achievement and rich experience can let me work to make the right choice, have more opportunities and achievements. at the same time, munication is very important, because it determines whether my pany has a good future development. so i need to exercise their municative ability. i need to use all of the free time to learn
世界经典哲学类书籍 哲学，是理论化、系统化的世界观，是自然知识、社会知识、思维知识的概括和总结,是世界观和方法论的统一。是社会意识的具体存在和表现形式，是以追求世界的本源、本质、共性或绝对、终极的形而上者为形式，以确立哲学世界观和方法论为内容的社会科学。 《性心理学》 《作为意志和表象的世界》 《理想国》 《西方哲学史》 《自然哲学的数学原理》 《权力意志》 《新工具》 《纯粹理性批判》《文明论概略》 《劝学篇》 《伦理学》 《耶稣传》 《时间简史》 《逻辑哲学论》 《精神现象学》 《物性论》 《感觉的分析》 《精神分析引论》《基督何许人也——基督抹煞论》 《科学的社会功能》《人有人的用处》《科学史》 《人类理智新论》《逻辑学》 《哲学研究》 《新系统及其说明》《道德情操论》 《实践理性批判》《美学》 《判断力批判》 《基督教的本质》《薄伽梵歌》 《伦理学中的形式主义与质料的价值伦理学》《物种起源》 《物理学》《人类的由来》 《人性论》 《人是机器》 《法哲学原理》 《狄德罗哲学选集》 《野性的思维》 《哲学史教程》 《科学与近代世界》 《人类的知识》 《精神分析引论新编》 《自然宗教对话录》 《基督教并不神秘》 《科学中华而不实的 作风》 《一年有半，续一年有 半》 《时间与自由意志》 《哲学辞典》 《历史理性批判文集》 《苏鲁支语录》 《文化科学和自然科 学》 《十六、十七世纪科 学、技术和哲学史》 《科学哲学的兴起》 《灵魂论及其他》 《斯宾诺莎书信集》 《实验心理学史》 《最后的沉思》 《纯粹现象学通论》 《近代心理学历史导 引》 《佛教逻辑》 《神圣人生论》 《逻辑与知识》 《论原因、本原与太 一》 《形而上学导论》 《诗学》 《路标》 《心的概念》 《计算机与人脑》 《十七世纪英格兰的 科学、技术与社会》 《卡布斯教诲录》 《薄伽梵歌论》 《尼各马可伦理学》 《论老年论友谊论责 任》 《实用主义》 《我的哲学的发展》 《拓扑心理学原理》 《在通向语言的途中》 《科学社会学》 《埃克哈特大师文集》 《逻辑大全》 《简论上帝、人及其心 灵健康》 《宗教的本质》 《论灵魂》 《科学的价值》 《内时间意识现象学》 《艺术即经验》 《宗教与科学》 《感觉与可感物》 《行为的结构》 《真理与方法》 《阿维斯塔》 《善的研究》 《人类知识原理》 《伦理学体系》 《科学与方法》 《第一哲学（上下卷）》 《物理学理论的目的 与结构》 《思维方式》 《发生认识论原理》 《爱因斯坦文集》 《伦理学的两个基本问题》 《数理哲学导论 《耶稣传（第一、二卷）》 《美学史》 《原始思维》 《面向思的事情》 《普通认识论》 《莱布尼茨与克拉克论战 书信集》 《对莱布尼茨哲学的批评 性解释》 《物理学和哲学》 《尼采（上下卷）》 《思想录》 《道德原则研究》 《自我的超越性》 《实验医学研究导论》 《巴曼尼得斯篇》 《人类理解论》 《笛卡尔哲学原理》 《人生的亲证》 《认识与谬误》 《哲学史讲演录》 《圣教论》 《哲学作为严格的科学》 《人类知识起源论》 《回忆苏格拉底》 《心的分析》 《任何一种能够作为科学 出现的未来形而上学导论》 《科学与假设》 《宗教经验之种种》 《声音与现象》 《苏格拉底的申辩》 《论个人在历史上的作用 问题》 《论有学识的无知》 《保卫马克思》 《艺术的起源》
关于坚持的英语演讲稿 Results are not important, but they can persist for many years as a commemoration of. Many years ago, as a result of habits and overeating formed one of obesity, as well as indicators of overall physical disorders, so that affects my work and life. In friends to encourage and supervise, the participated in the team Now considered to have been more than three years, neither the fine rain, regardless of winter heat, a day out with 5:00 time. The beginning, have been discouraged, suffering, and disappointment, but in the end of the urging of friends, to re-get up, stand on the playground. 成绩并不重要，但可以作为坚持多年晨跑的一个纪念。多年前，由于庸懒习惯和暴饮暴食，形成了一身的肥胖，以及体检指标的全盘失常，以致于影响到了我的工作和生活。在好友的鼓励和督促下，参加了晨跑队伍。现在算来，已经三年多了，无论天晴下雨，不管寒冬酷暑，每天五点准时起来出门晨跑。开始时，也曾气馁过、痛苦过、失望过，但最后都在好友们的催促下，重新爬起来，站到了操场上。 In fact, I did not build big, nor strong muscles, not a sport-born people. Over the past few years to adhere to it, because I have a team behind, the strength of a strongteam here, very grateful to our team, for a long time, we encourage each other, and with sweat, enjoying common health happy. For example, Friends of the several run in order to maintain order and unable to attend the 10，000 meters race, and they are always concerned about the brothers and promptly inform the place and time, gives us confidence and courage. At the same time, also came on their own inner desire and pursuit for a good health, who wrote many of their own log in order to refuel for their own, and inspiring. 其实我没有高大身材，也没健壮肌肉，天生不属于运动型的人。几年来能够坚持下来，因为我的背后有一个团队，有着强大团队的力量，在这里，非常感谢我们的晨跑队，长期以来，我们相互鼓励着，一起流汗，共同享受着健康带来的快
1.How to build a business that lasts100years 0:11Imagine that you are a product designer.And you've designed a product,a new type of product,called the human immune system.You're pitching this product to a skeptical,strictly no-nonsense manager.Let's call him Bob.I think we all know at least one Bob,right?How would that go? 0:34Bob,I've got this incredible idea for a completely new type of personal health product.It's called the human immune system.I can see from your face that you're having some problems with this.Don't worry.I know it's very complicated.I don't want to take you through the gory details,I just want to tell you about some of the amazing features of this product.First of all,it cleverly uses redundancy by having millions of copies of each component--leukocytes,white blood cells--before they're actually needed,to create a massive buffer against the unexpected.And it cleverly leverages diversity by having not just leukocytes but B cells,T cells,natural killer cells,antibodies.The components don't really matter.The point is that together,this diversity of different approaches can cope with more or less anything that evolution has been able to throw up.And the design is completely modular.You have the surface barrier of the human skin,you have the very rapidly reacting innate immune system and then you have the highly targeted adaptive immune system.The point is,that if one system fails,another can take over,creating a virtually foolproof system. 1:54I can see I'm losing you,Bob,but stay with me,because here is the really killer feature.The product is completely adaptive.It's able to actually develop targeted antibodies to threats that it's never even met before.It actually also does this with incredible prudence,detecting and reacting to every tiny threat,and furthermore, remembering every previous threat,in case they are ever encountered again.What I'm pitching you today is actually not a stand-alone product.The product is embedded in the larger system of the human body,and it works in complete harmony with that system,to create this unprecedented level of biological protection.So Bob,just tell me honestly,what do you think of my product? 2:47And Bob may say something like,I sincerely appreciate the effort and passion that have gone into your presentation,blah blah blah-- 2:56(Laughter) 2:58But honestly,it's total nonsense.You seem to be saying that the key selling points of your product are that it is inefficient and complex.Didn't they teach you 80-20?And furthermore,you're saying that this product is siloed.It overreacts, makes things up as it goes along and is actually designed for somebody else's benefit. I'm sorry to break it to you,but I don't think this one is a winner.
关于工作的优秀英语演讲稿 Different people have various ambitions. Some want to be engineers or doctors in the future. Some want to be scientists or businessmen. Still some wish to be teachers or lawers when they grow up in the days to come. Unlike other people, I prefer to be a farmer. However, it is not easy to be a farmer for Iwill be looked upon by others. Anyway,what I am trying to do is to make great contributions to agriculture. It is well known that farming is the basic of the country. Above all, farming is not only a challenge but also a good opportunity for the young. We can also make a big profit by growing vegetables and food in a scientific way. Besides we can apply what we have learned in school to farming. Thus our countryside will become more and more properous. I believe that any man with knowledge can do whatever they can so long as this job can meet his or her interest. All the working position can provide him with a good chance to become a talent. 1 ————来源网络整理，仅供供参考
尊敬的领导，老师，亲爱的同学们， 大家好！我是5班的梁浩东。今天早上我坐车来学校的路上，我仔细观察了路上形形色色的人，有开着小车衣着精致的叔叔阿姨，有市场带着倦容的卖各种早点的阿姨，还有偶尔穿梭于人群中衣衫褴褛的乞丐。于是我问自己，十几年后我会成为怎样的自己，想成为社会成功人士还是碌碌无为的人呢，答案肯定是前者。那么十几年后我怎样才能如愿以偿呢，成为一个受人尊重，有价值的人呢？正如我今天演讲的题目是：自主管理。 大家都知道爱玩是我们孩子的天性，学习也是我们的责任和义务。要怎样处理好这些矛盾，提高自主管理呢？ 首先，我们要有小主人翁思想，自己做自己的主人，要认识到我们学习，生活这一切都是我们自己走自己的人生路，并不是为了报答父母，更不是为了敷衍老师。 我认为自主管理又可以理解为自我管理，在学习和生活中无处不在，比如通过老师，小组长来管理约束行为和同学们对自身行为的管理都属于自我管理。比如我们到一个旅游景点，看到一块大石头，有的同学特别兴奋，会想在上面刻上：某某某到此一游话。这时你就需要自我管理，你需要提醒自己，这样做会破坏景点，而且是一种素质低下的表现。你设想一下，如果别人家小孩去你家墙上乱涂乱画，你是何种感受。同样我们把自主管理放到学习上，在我们想偷懒，想逃避，想放弃的时候，我们可以通过自主管理来避免这些，通过他人或者自己的力量来完成。例如我会制定作息时间计划表，里面包括学习，运动，玩耍等内容的完成时间。那些学校学习尖子，他们学习好是智商高于我们吗，其实不然，在我所了解的哪些优秀的学霸传授经验里，就提到要能够自我管理，规范好学习时间的分分秒秒，只有辛勤的付出，才能取得优异成绩。 在现实生活中，无数成功人士告诉我们自主管理的重要性。十几年后我想成为一位优秀的，为国家多做贡献的人。亲爱的同学们，你们们？让我们从现在开始重视和执行自主管理，十几年后成为那个你想成为的人。 谢谢大家！
关于工作的英语演讲稿 【篇一：关于工作的英语演讲稿】 关于工作的英语演讲稿 different people have various ambitions. some want to be engineers or doctors in the future. some want to be scientists or businessmen. still some wish to be teachers or lawers when they grow up in the days to come. unlike other people, i prefer to be a farmer. however, it is not easy to be a farmer for iwill be looked upon by others. anyway,what i am trying to do is to make great contributions to agriculture. it is well known that farming is the basic of the country. above all, farming is not only a challenge but also a good opportunity for the young. we can also make a big profit by growing vegetables and food in a scientific way. besides we can apply what we have learned in school to farming. thus our countryside will become more and more properous. i believe that any man with knowledge can do whatever they can so long as this job can meet his or her interest. all the working position can provide him with a good chance to become a talent. 【篇二：关于责任感的英语演讲稿】 im grateful that ive been given this opportunity to stand here as a spokesman. facing all of you on the stage, i have the exciting feeling of participating in this speech competition. the topic today is what we cannot afford to lose. if you ask me this question, i must tell you that i think the answer is a word---- responsibility. in my elementary years, there was a little girl in the class who worked very hard, however she could never do satisfactorily in her lessons. the teacher asked me to help her, and it was obvious that she expected a lot from me. but as a young boy, i was so restless and thoughtless, i always tried to get more time to play and enjoy myself. so she was always slighted over by me. one day before the final exam, she came up to me and said, could you please explain this to me? i can not understand it. i
第五章老年社会工作 第一节老年社会工作概述 第二节老年社会工作的主要内容 第三节老年社会工作的主要方法 第一节老年社会工作概述 一、老年人与老年期 （一）年龄界定 生理年龄：生理指标与功能确定 心理年龄：心理活动程度确定 社会年龄：与他人交往的角色确定 （二）老年期的划分 低龄老年人：60-69岁 中龄老年人：70-79 高龄老年人：80岁以上 （三）划分的意义 1.三种年龄：不能仅凭日历年龄判断服务需求，而要关注不同个体在生理、心理与社会方面的差异。 2.三个时期：关注老年同期群的共性需要。 二、老年期的特点 （一）生理变化 1.生理变化的特点：九大生理系统老化 2.对开展老年社会工作的影响 （1）要特别关注老年人的身体健康状况； （2）处理好隐私的健康问题，如大小便； （3）帮助机构和家庭策划环境的调整。 （二）心理变化 1.智力、人格、记忆力的变化 智力：结晶智力强，但处理问题速度下降 人格：总结自己生命的意义 记忆力：记忆速度下降，动机决定是否学习 2.对开展老年社工的影响 （1）提供机会但尊重选择 （2）所有事放慢节奏 （3）关注身体健康对心理功能的重要性 （三）社会生活方面的变化 1.对老年社会生活变化的理论解释 （1）角色理论：丧失象征中年的社会角色 （2）活动理论：生活满足感与活动有积极联系 （3）撤离理论：接受减少与社会的交往 （4）延续理论：不能割裂看待老年阶段 （5）社会建构理论：老年是一个独特的个人过程 （6）现代化理论：现代化使老年人地位下降
2.理论在社会工作中的应用 （1）注意角色转变的重大生活事件 （2）注意老年个体的差异性，尊重其对生活意义的不同理解 （3）注意社会隔离可能对老年人造成的伤害 （4）改变总有可能 （5）关注社会变迁对老年人的影响，推动社会政策的调整 三、老年人的需要及问题 （一）老年人的需要 1.健康维护 2.经济保障 3.就业休闲 4.社会参与 5.婚姻家庭 6.居家安全 7.后事安排 8.一条龙照顾 （二）老年人的问题 1.慢性病问题与医疗问题 2.家庭照顾问题 3.宜居环境问题 4.代际隔阂问题 5.社会隔离问题 四、老年社会工作 （一）老年社会工作的对象 1.老年人自身：空巢、残疾、高龄老人，也包括健康老人 2.老年人周围的人：家庭成员、亲属、朋友、邻居等 3.宏观系统：单位与服务组织 （二）老年社会工作的目的 根本目标：老有所养、老有所医、老有所教、老有所学、老有所为、老有所乐 （三）老年社会工作的作用 1.个体层面：维持日常生活、获得社会支持 2.宏观层面：参与制定有关老年人的服务方案与政策 五、老年社会工作的特点 （一）老年歧视等社会价值观会影响社会工作者的态度与行为 （二）反移情是社会工作者的重要课题 （三）社会工作者要善于运用督导机制 （四）需要多学科合作 第二节老年社会工作的主要内容 一、身体健康方面的服务 二、认知与情绪问题的处理 三、精神问题的解决 四、社会支持网络的建立 五、老年人特殊问题的处理 一、身体健康方面的服务
Dear teacher and colleagues: my topic is on “spare time”. It is a huge blessing that we can work 996. Jack Ma said at an Ali's internal communication activity, That means we should work at 9am to 9pm, 6 days a week .I question the entire premise of this piece. but I'm always interested in hearing what successful and especially rich people come up with time .So I finally found out Jack Ma also had said :”i f you don’t put out more time and energy than others ,how can you achieve the success you want? If you do not do 996 when you are young ,when will you ?”I quite agree with the idea that young people should fight for success .But there are a lot of survival activities to do in a day ,I want to focus on how much time they take from us and what can we do with the rest of the time. As all we known ,There are 168 hours in a week .We sleep roughly seven-and-a-half and eight hours a day .so around 56 hours a week . maybe it is slightly different for someone . We do our personal things like eating and bathing and maybe looking after kids -about three hours a day .so around 21 hours a week .And if you are working a full time job ,so 40 hours a week , Oh! Maybe it is impossible for us at
关于人英语演讲稿(精选多篇) 关于人的优美句子 1、“黑皮小子”是我对在公交车上偶遇两次的一个男孩的称呼代号。一听这个外号，你也定会知道他极黑了。他的脸总是黑黑的；裸露在短袖外的胳膊也是黑黑的；就连两只有厚厚耳垂的耳朵也那么黑黑的，时不时像黑色的猎犬竖起来倾听着什么；黑黑的扁鼻子时不时地深呼吸着，像是在警觉地嗅着什么异样的味道。 2、我不知道，如何诠释我的母亲，因为母亲淡淡的生活中却常常跳动着不一样的间最无私、最伟大、最崇高的爱，莫过于母爱。无私，因为她的爱只有付出，无需回报；伟大，因为她的爱寓于
普通、平凡和简单之中；崇高，是因为她的爱是用生命化作乳汁，哺育着我，使我的生命得以延续，得以蓬勃，得以灿烂。 3、我的左撇子伙伴是用左手写字的，就像我们的右手一样挥洒自如。在日常生活中，曾见过用左手拿筷子的，也有像超级林丹用左手打羽毛球的，但很少碰见用左手写字的。中国汉字笔画笔顺是左起右收，适合用右手写字。但我的左撇子伙伴写字是右起左收的，像鸡爪一样迈出田字格，左看右看，上看下看，每一个字都很难看。平时考试时间终了，他总是做不完试卷。于是老师就跟家长商量，决定让他左改右写。经过老师引导，家长配合，他自己刻苦练字，考试能够提前完成了。现在他的字像他本人一样阳光、帅气。 4、老师，他们是辛勤的园丁，帮助着那些幼苗茁壮成长。他们不怕辛苦地给我们改厚厚一叠的作业，给我们上课。一步一步一点一点地给我们知识。虽然
他们有时也会批评一些人，但是他们的批评是对我们有帮助的，我们也要理解他们。那些学习差的同学，老师会逐一地耐心教导，使他们的学习突飞猛进。使他们的耐心教导培养出了一批批优秀的人才。他们不怕辛苦、不怕劳累地教育着我们这些幼苗，难道不是美吗？ 5、我有一个表妹，还不到十岁，她那圆圆的小脸蛋儿，粉白中透着粉红，她的头发很浓密，而且好像马鬓毛一样的粗硬，但还是保留着孩子一样的蓬乱的美，卷曲的环绕着她那小小的耳朵。说起她，她可是一个古灵精怪的小女孩。 6、黑皮小子是一个善良的人，他要跟所有见过的人成为最好的朋友！这样人人都是他的好朋友，那么人人都是好友一样坦诚、关爱相交，这样人与人自然会和谐起来，少了许多争执了。 7、有人说，老师是土壤，把知识化作养分，传授给祖国的花朵，让他们茁壮成长。亦有人说，老师是一座知识的桥梁，把我们带进奇妙的科学世界，让
关于时间的英语演讲稿范文_演讲稿 and organizing people to learn from advanced areas to broaden their horizons in order to understand the team of cadres working conditions in schools, the ministry of education has traveled a number of primary and secondary schools to conduct research, listen to the views of the school party and government leaders to make school leadership cadres receive attention and guidance of the ministry of education to carry out a variety of practical activities to actively lead the majority of young teachers work hard to become qualified personnel and for them to put up the cast talent stage, a single sail swaying, after numerous twists and turns arrived in port, if there is wind, a hand, and naturally smooth arrival and guide students to strive to e xcel, need to nazhen “wind” - teacher. teachers should be ideological and moral education, culture education and the needs of students organically combining various activities for the students or students to carry out their own. for example: school quiz competitions, essay contests, ke benju performances and other activities to enable students to give full play to their talents. teachers rush toil, in order to that will enable students to continue to draw nutrients, to help them grow up healthily and become pillars of the country before. for all students in general education, the government departments have also not forget those who cared about the
good afternoon everybody! I’m very glad to stand here and give you a short speech about challenge and opportunity,双手交握微笑 So, what’s an opportunity? It’s a great chance to achieve dreams, it’s a platform to show ourselves.Just as now,I’m standing here showing myself,it's one of my dreams,also my opportunity. Then, what about challenge? Challenge is a new or difficult task which test our ability and skill. it is a fighter, a sense of courage, the fearless spirit towards all difficulties, Many people are afraid of being challenged, worrying about change and failure.I used to be a member of them，but now,I find that sth we haven’t done isn’t as difficult as it seems, fear always hindered our courage. Said so much,此刻我最想与你们分享的一句话就是： we should welcome being challenged,and try to enjoy it.它很可能是你进步的机会 Cruel competition isn 't the excuse for failure. No one is regularly on a winner or a loser. To the strong willed, competition is the spring of hope; To the weak minded, it means the winter of despair. So turning into opportunities means taking advantage of these challenges and benefiting from them.In this way,you can be the boss of your life.这句语法有没有错误？指着他，手势 That’s all, thank you!