Health systems globally are exploring new models of care to address the increasing demand for palliative, hospice, and end-of-life care. Yet few tools exist at the population level to explore "what if" scenarios and test, in a "cost avoidance environment," the impact of these new care models on policy, workforce, technology, and funding. This article introduces the application of scenario-based "what if" thinking and discrete event simulation in strategic planning for a not-for-profit hospice organization. It will describe how a set of conceptual models was designed to frame discussions between strategic partners about the implications and alternatives in implementing a new, integrated service model for palliative and end-of-life care.

Change management is more important than ever in healthcare. It is an essential part of the management tool box and to downplay its importance is to risk serious challenges, including failure, in implementing and even more importantly, sustaining change. All too often, change management is something that is handed off to a special department or even contracted out, without due consideration of the need to develop the knowledge and skills in and across the organization. Some basics for successful change management are identified and discussed.

Gestational diabetes mellitus (GDM) affects 5 % of all pregnancies, making it the most common complication of pregnancy today.' Yet a recent study found that only 41 % of physicians routinely screen pregnant women for diabetes. In addition, fewer than half use the recommended method of diagnosing gestational diabetes.2Gestational diabetes is usually diagnosed during the second half of pregnancy because that is when the mother's insulin needs rise as her body greatly increases the amount of nourishment to the baby. If the mothers pancreas cannot produce enough insulin, or if her insulinis not used effectively, gestational diabetes results.The Second International Workshop -Conference on Gestational Diabetes Mellitus, held in October 1984, defined GDM as &dquo;carbohydrate intolerance of variable severity with onset or first recognition during the present pregnancy. &dquo;3 This definition applies whether or not insulin is used for treatment and whether or not the condition persists after pregnancy. It does not preclude the possibility that the condition existed prior to the present pregnancy and/or that it may be permanent.In 97.5 % of women diagnosed with gestational diabetes, the condition disappears at the end of the pregnancy.4 However, approximately 60% of women with GDM develop overt diabetes mellitus within 20 years following the pregnancy if they are overweight and remain overweight.4 Maintaining desirable body weight, exercise, and optimal nutrition reduces the likelihood to 25%. is a large birth weight for the baby. This can result in significant injury to the infant and cause trauma to the mother during delivery. It is also one reason for the increased incidence of caesarean sections for women with diabetes mellitus.5 Other risks to the mother and baby are outlined in Table 1. The question of whether congenital anomalies occur more often among infants of women with GDM remains unanswered. ScreeningIn the past, most physicians have attempted to identify women with GDM by defining those at &dquo;high risk&dquo; based on maternal, historical, or clinical risk factors. Such factors include a history of stillbirth or miscarriage, a family member with diabetes, previous delivery of an infant weighing more than 9 lb (4,000 g) at birth, a previous pregnancy complicated by GDM, obesity in the mother, a high maternal age, parity of five or more, and glycosuria, urinary tract infections, hydramnios, or a history of toxemia in the mother. This high-risk group, once identified, is then tested for abnormal carbohydrate metabolism. Recent research has revealed that screening pregnant women on the basis of the above risk factors alone will detect only 50% of all cases of GDM . M any patients diagnosed with GDM exhibit no risk factors. For this reason. the American Diabetes Association recommended in 1985 that all pregnant women be screened for abnormal glucose metabolism between the 24th and 28th weeks of gestation.The correct screening method for gestational diabetes involves giving the pregnant woman a 50-g oral g...

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