Friday, April 13, 2007
Wellness for the subacute patient: even though they're more acutely ill than most nursing home residents, subacute patients can use wellness programs,
Wouldn't it be fabulous if nursing homes were paid for empty beds rather than being reimbursed for filled ones?" asks Cheryl Field, MSN, RN, CRRN, director of Clinical and Reimbursement Services at LTCQ, Inc., in Lexington, Massachusetts. "If that were the case, they'd do better at keeping people well in the community."
Obviously, the reimbursement system will never change that dramatically. But the possibility of not only getting people well, but keeping them that way, does exist in the subacute care community. The best place to start, says Field and others in the industry, is through the introduction of wellness programs.
Such programs are indeed beginning to spring up in subacute facilities throughout the United States, offering a holistic approach to getting short-term residents back on their feet and keeping them from coming back to the SNF. But unlike restorative programs, in which the goal is to maintain a long-term care resident's highest level of function, wellness programs are meant to wean subacute patients away from their reliance on facility staff and toward self-reliant living at home.
Kathleen Sullivan, RN, MN, CS, CRRN, is assistant director of nurses at Greenbriar Terrace Healthcare in Nashua, New Hampshire, a 300-bed facility with 55 beds licensed for skilled subacute care. As part of the Kindred Healthcare chain, Greenbriar uses the Care Map, a proprietary tool that effects a seamless transition from hospital to Greenbriar to home (figure). "As they come through our doors, we have two sets of goals in mind: short-term and long-term," says Sullivan. "For the short term, we have to make sure that we are able to pick them up from the hospital level of care--be it IV therapy, PT, or whatever was going on at the hospital--and then continue treatment. As far as long-term goals, we sit down with the patient, family members, case manager, and a representative from nursing to construct the Care Map. We plan out what we need to do to get patients back to their prior level of function. We also need to ask some basic questions, such as 'How many steps are there to get into the house?' Knowing what questions to ask is a big thing."
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[ILLUSTRATION OMITTED]
There was never a question as to whether Mrs. Thomas was going to go right home after her discharge from the hospital. She'd been admitted with a diagnosis of cellulitis, which developed after she badly cut her lower left leg while closing a car door. She was responding well to IV antibiotics and would have been able to return home with the help of visiting nurse services, which would continue to oversee therapy. But Mrs. Thomas would not allow "strangers" into her home, plus she needed help with wound care. Neither of these conditions would have qualified her for Medicare benefits to cover her stay at Greenbriar, but the fact that she suffered from congestive heart failure did. Because she was spending so much time in bed, muscle weakness was setting in and fluid was gathering in her legs.
Once at Greenbriar, Mrs. Thomas received PT five days a week. They encouraged her to be up and about for specific periods throughout the day. When she was in her room, her legs were elevated to promote circulation and healing.
All was well until about day 14, when she became agitated, saying that she "needed to take care of some business." She fully intended to leave against medical advice. And that's where the Care Map kicked in. Adjustments were made, and Greenbriar's staff worked with Mrs. Thomas so that she felt free to address her business, leaving her confident that she remained in charge of her life. As a result, when she was discharged after nearly a six-week stay, she was able to resume her life where she had left off. She'd had sufficient time to practice climbing stairs at Greenbriar, was better able to understand her medication schedule, and was proficient at the minimal self-care her wound still needed after practicing with the nursing staff.
Had she gone home when she wanted to, Mrs. Thomas could have injured herself as she tried to cope alone, possibly ending up back at the hospital. The Care Map--the wellness component of her care plan--was her safety net.
"All in all, without the Care Map, somebody could really fail badly from either lack of preparation or from being discharged from subacute too quickly," says Sullivan. "In the dollars and cents of it all, if this is done correctly, the patient won't go back to the hospital, which is a much larger daily cost."
"We used to call it a phaseout, as in 'let's phase us out of their lives,'" notes Field. But now the push is for more than just mobility--it's for the promotion of restored independence. "Basically we're teaching patients how to seek out the services they need or acquire their medicine on their own so we can make sure they've learned these new behaviors and can maintain and use these new skills at home." Field also suggests that, for example, as a subacute patient nears the end of her stay, she have her own bedspread at the facility so that the week before discharge, she can practice making her own bed: "If she's going to trip on her bedspread, let her do it here so we can teach her how to avoid it. The bottom line is that right now, the way things are, we're creating dependent people. We should encourage them to do things for themselves a week before they leave instead of returning home and having problems.
Obviously, the reimbursement system will never change that dramatically. But the possibility of not only getting people well, but keeping them that way, does exist in the subacute care community. The best place to start, says Field and others in the industry, is through the introduction of wellness programs.
Such programs are indeed beginning to spring up in subacute facilities throughout the United States, offering a holistic approach to getting short-term residents back on their feet and keeping them from coming back to the SNF. But unlike restorative programs, in which the goal is to maintain a long-term care resident's highest level of function, wellness programs are meant to wean subacute patients away from their reliance on facility staff and toward self-reliant living at home.
Kathleen Sullivan, RN, MN, CS, CRRN, is assistant director of nurses at Greenbriar Terrace Healthcare in Nashua, New Hampshire, a 300-bed facility with 55 beds licensed for skilled subacute care. As part of the Kindred Healthcare chain, Greenbriar uses the Care Map, a proprietary tool that effects a seamless transition from hospital to Greenbriar to home (figure). "As they come through our doors, we have two sets of goals in mind: short-term and long-term," says Sullivan. "For the short term, we have to make sure that we are able to pick them up from the hospital level of care--be it IV therapy, PT, or whatever was going on at the hospital--and then continue treatment. As far as long-term goals, we sit down with the patient, family members, case manager, and a representative from nursing to construct the Care Map. We plan out what we need to do to get patients back to their prior level of function. We also need to ask some basic questions, such as 'How many steps are there to get into the house?' Knowing what questions to ask is a big thing."
Advertisement
[ILLUSTRATION OMITTED]
There was never a question as to whether Mrs. Thomas was going to go right home after her discharge from the hospital. She'd been admitted with a diagnosis of cellulitis, which developed after she badly cut her lower left leg while closing a car door. She was responding well to IV antibiotics and would have been able to return home with the help of visiting nurse services, which would continue to oversee therapy. But Mrs. Thomas would not allow "strangers" into her home, plus she needed help with wound care. Neither of these conditions would have qualified her for Medicare benefits to cover her stay at Greenbriar, but the fact that she suffered from congestive heart failure did. Because she was spending so much time in bed, muscle weakness was setting in and fluid was gathering in her legs.
Once at Greenbriar, Mrs. Thomas received PT five days a week. They encouraged her to be up and about for specific periods throughout the day. When she was in her room, her legs were elevated to promote circulation and healing.
All was well until about day 14, when she became agitated, saying that she "needed to take care of some business." She fully intended to leave against medical advice. And that's where the Care Map kicked in. Adjustments were made, and Greenbriar's staff worked with Mrs. Thomas so that she felt free to address her business, leaving her confident that she remained in charge of her life. As a result, when she was discharged after nearly a six-week stay, she was able to resume her life where she had left off. She'd had sufficient time to practice climbing stairs at Greenbriar, was better able to understand her medication schedule, and was proficient at the minimal self-care her wound still needed after practicing with the nursing staff.
Had she gone home when she wanted to, Mrs. Thomas could have injured herself as she tried to cope alone, possibly ending up back at the hospital. The Care Map--the wellness component of her care plan--was her safety net.
"All in all, without the Care Map, somebody could really fail badly from either lack of preparation or from being discharged from subacute too quickly," says Sullivan. "In the dollars and cents of it all, if this is done correctly, the patient won't go back to the hospital, which is a much larger daily cost."
"We used to call it a phaseout, as in 'let's phase us out of their lives,'" notes Field. But now the push is for more than just mobility--it's for the promotion of restored independence. "Basically we're teaching patients how to seek out the services they need or acquire their medicine on their own so we can make sure they've learned these new behaviors and can maintain and use these new skills at home." Field also suggests that, for example, as a subacute patient nears the end of her stay, she have her own bedspread at the facility so that the week before discharge, she can practice making her own bed: "If she's going to trip on her bedspread, let her do it here so we can teach her how to avoid it. The bottom line is that right now, the way things are, we're creating dependent people. We should encourage them to do things for themselves a week before they leave instead of returning home and having problems.
Work-at-home scheme
I was ripped off by a work-at-home business, but when I tried to return the package, it was refused.
I So I put it in a new box and mailed it again at my expense. I filed a complaint with the U.S. Postal Inspection Service and the BBB, but neither has been able to help me. The company was hiding behind a post office box and did not give me a real contact phone number or address. Is there any way I can get my money back without shelling out more cash?
--K. Utley
Via the Internet
Before we go into how to get your money back, let's talk a little about work-at-home operations. Although there are many legitimate work-at-home jobs, it's a good idea to ask the following questions before committing:
* What tasks will I have to perform?
* How will I get paid?
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* Will I be paid a salary or a commission?
* When can I expect my first paycheck?
* Is there a long-term obligation that I should know about?
* What will I get for my money?
In addition, investigate the company by requesting written materials by mail, including product and service information or info about the organization itself. If there is an investment or purchase involved, have that information sent to your lawyer, accountant, or financial adviser for review.
You may file a complaint with the FTC (877-382-4357; www.ftc.gov), your local consumer protection offices, and the advertising manager of the publication that ran the ad. Also read Work-at-Home Directory by Barbara Becker (Prime Pub Inc.; $3.95) and read "Don't Let Seam Artists Trap You," (February 2003).
I So I put it in a new box and mailed it again at my expense. I filed a complaint with the U.S. Postal Inspection Service and the BBB, but neither has been able to help me. The company was hiding behind a post office box and did not give me a real contact phone number or address. Is there any way I can get my money back without shelling out more cash?
--K. Utley
Via the Internet
Before we go into how to get your money back, let's talk a little about work-at-home operations. Although there are many legitimate work-at-home jobs, it's a good idea to ask the following questions before committing:
* What tasks will I have to perform?
* How will I get paid?
Advertisement
* Will I be paid a salary or a commission?
* When can I expect my first paycheck?
* Is there a long-term obligation that I should know about?
* What will I get for my money?
In addition, investigate the company by requesting written materials by mail, including product and service information or info about the organization itself. If there is an investment or purchase involved, have that information sent to your lawyer, accountant, or financial adviser for review.
You may file a complaint with the FTC (877-382-4357; www.ftc.gov), your local consumer protection offices, and the advertising manager of the publication that ran the ad. Also read Work-at-Home Directory by Barbara Becker (Prime Pub Inc.; $3.95) and read "Don't Let Seam Artists Trap You," (February 2003).
Process control and information systems
merson Process Management is a leader in helping businesses automate their production, processing, and distribution in the petrochemical, oil and gas and refining industries. The company combines superior products and technology with industry-specific engineering, consulting, project management, and maintenance services. Emerson brands include: PlantWeb[R]; DeltaV[TM]; Fisher[R]; Micro Motion[R]; Rosemount[R]; Daniel[R]; Ovation[R]; and AMS[TM] Suite.
Products:
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DeltaV Operations Software. The DeltaV Operate provides a state-of-the-art environment for process operations, with built-in features for easy information access. Whether you're viewing the highest priority alarm, the next display, detailed module information, or historical trends, common operator navigation is consistent, intuitive and easy. See EasyDeltaV. com for more information.
DeltaV Configuration Software Suite. You can easily manage all aspects of your system configuration including hardware configuration, history, OPC, and control strategies in workstations, controllers and even field devices. See EasyDeltaV.com for more information.
Maintenance Station Software Suite. Includes rich graphics, calibration and diagnostics capabilities. You can view standard fieldbus alerts and PlantWeb alerts, which are more intelligent alerts provided by Emerson fieldbus devices. These PlantWeb alerts categorize the problem severity and provides recommended resolution paths. See EasyDeltaV.com for more information.
PlantWeb Messenger Alert Reporting Service. PlantWeb Messenger is a suite of applications that work together seamlessly to support the exchange of data between Emerson Process Management applications and users and business systems within your enterprise. The PlantWeb Messenger Alert Reporting Service allows enterprise users to have alert reports that will be delivered directly to them whenever a critical device alert, process alarm or system event occurs--via email, phone, PDA, pager, or XML file. See EasyDeltaV.com for more information.
DeltaV Web Server. With the DeltaV Web Server you can view your plant process graphics in any standard web browser, from anywhere in the world, even from home! You'll find that the value of widespread information can be an incalculable asset in your plant, giving decision-making tools to the people closest to the process, and giving them the power to make the right decisions. See EasyDeltaV.com for more information.
DeltaV OPC Server. Built upon the latest OPC data server specification for real-time process data, the DeltaV OPC Server provides a convenient way to get real-time information from your automation system and into a standards-based OPC client application for easy plugand-play connectivity. See EasyDeltaV.com for more information.
DeltaV OPC Events Server. Built upon the latest OPC Alarms and Events specification, the DeltaV OPC Events Server provides a convenient way to get data out of the DeltaV alarms and events subsystem and into an OPC Alarms and Events client application for easy plugand-play connectivity. See EasyDeltaV.com for more information.
OPC Mirror. Now, tying your plant information together is easier than ever, with Emerson's OPC Mirror. You get seamless drag and drop connectivity between OPC servers. Just download the lite version of OPC Mirror at EasyDeltaV.com/OPCMirror/ It's FREE! And, start realizing multi-vendor hardware and software interoperability plant-wide--easy.
OPC Pager. By monitoring data available from your OPC server, the OPC Pager is your constant watchdog, keeping an eye on your critical values and notifying you when they meet your alert criteria. See EasyDeltaV.com for more information.
DeltaV Tune. Reduces process variability with the patented autotuner technology. The embedded DeltaV Tune works with both PID and fuzzy logic-based control to improve process operations. See EasyDeltaV.com for more information.
DeltaV Inspect. Provides advanced process monitoring system that instantly identifies underperforming loops. This easy-to-use, no configuration required interface ensures a finely tuned process that produces on-spec products at optimal cost. See EasyDeltaV.com for more information.
PlantWeb Messenger Inspect Reporting Service. you can have Inspect reports and have them delivered directly to you--via email, phone, PDA, pager, or XML file. See EasyDeltaV.com for more information.
DeltaV Fuzzy. Embeds easy to use fuzzy logic control into the DeltaV configuration application as a standard function block. Since this fuzzy controller can be autotuned, it is now as easy as PID control for users to implement for loops with difficult dynamics, unmeasured disturbances, and large load/setpoint changes. See EasyDeltaV.com for more information.
Products:
Advertisement
DeltaV Operations Software. The DeltaV Operate provides a state-of-the-art environment for process operations, with built-in features for easy information access. Whether you're viewing the highest priority alarm, the next display, detailed module information, or historical trends, common operator navigation is consistent, intuitive and easy. See EasyDeltaV. com for more information.
DeltaV Configuration Software Suite. You can easily manage all aspects of your system configuration including hardware configuration, history, OPC, and control strategies in workstations, controllers and even field devices. See EasyDeltaV.com for more information.
Maintenance Station Software Suite. Includes rich graphics, calibration and diagnostics capabilities. You can view standard fieldbus alerts and PlantWeb alerts, which are more intelligent alerts provided by Emerson fieldbus devices. These PlantWeb alerts categorize the problem severity and provides recommended resolution paths. See EasyDeltaV.com for more information.
PlantWeb Messenger Alert Reporting Service. PlantWeb Messenger is a suite of applications that work together seamlessly to support the exchange of data between Emerson Process Management applications and users and business systems within your enterprise. The PlantWeb Messenger Alert Reporting Service allows enterprise users to have alert reports that will be delivered directly to them whenever a critical device alert, process alarm or system event occurs--via email, phone, PDA, pager, or XML file. See EasyDeltaV.com for more information.
DeltaV Web Server. With the DeltaV Web Server you can view your plant process graphics in any standard web browser, from anywhere in the world, even from home! You'll find that the value of widespread information can be an incalculable asset in your plant, giving decision-making tools to the people closest to the process, and giving them the power to make the right decisions. See EasyDeltaV.com for more information.
DeltaV OPC Server. Built upon the latest OPC data server specification for real-time process data, the DeltaV OPC Server provides a convenient way to get real-time information from your automation system and into a standards-based OPC client application for easy plugand-play connectivity. See EasyDeltaV.com for more information.
DeltaV OPC Events Server. Built upon the latest OPC Alarms and Events specification, the DeltaV OPC Events Server provides a convenient way to get data out of the DeltaV alarms and events subsystem and into an OPC Alarms and Events client application for easy plugand-play connectivity. See EasyDeltaV.com for more information.
OPC Mirror. Now, tying your plant information together is easier than ever, with Emerson's OPC Mirror. You get seamless drag and drop connectivity between OPC servers. Just download the lite version of OPC Mirror at EasyDeltaV.com/OPCMirror/ It's FREE! And, start realizing multi-vendor hardware and software interoperability plant-wide--easy.
OPC Pager. By monitoring data available from your OPC server, the OPC Pager is your constant watchdog, keeping an eye on your critical values and notifying you when they meet your alert criteria. See EasyDeltaV.com for more information.
DeltaV Tune. Reduces process variability with the patented autotuner technology. The embedded DeltaV Tune works with both PID and fuzzy logic-based control to improve process operations. See EasyDeltaV.com for more information.
DeltaV Inspect. Provides advanced process monitoring system that instantly identifies underperforming loops. This easy-to-use, no configuration required interface ensures a finely tuned process that produces on-spec products at optimal cost. See EasyDeltaV.com for more information.
PlantWeb Messenger Inspect Reporting Service. you can have Inspect reports and have them delivered directly to you--via email, phone, PDA, pager, or XML file. See EasyDeltaV.com for more information.
DeltaV Fuzzy. Embeds easy to use fuzzy logic control into the DeltaV configuration application as a standard function block. Since this fuzzy controller can be autotuned, it is now as easy as PID control for users to implement for loops with difficult dynamics, unmeasured disturbances, and large load/setpoint changes. See EasyDeltaV.com for more information.
The great online job hunt: navigate the Net to find the best career information
Megan Fong looked ahead to college, she hoped to find an internship or a summer job in the entertainment industry. She decided to look online. Fong noticed an ad on craigslist (www.craigslist.org), a Web site featuring job openings from cities around the country. ManiaTV!--a new Internet television network--was seeking on-air personalities. Fong responded immediately. The next thing she knew, she was called in for an audition. After several more auditions, she landed a job as one of the network's first CJs (cyberjockeys).
Now an 18-year-old freshman at the University of Denver, Fong hosts two music-video shows and a spoof of the online dating scene on ManiaTV! while carrying a full course load. "My job is amazing," she says. "I am getting hands-on experience, plus it's so much fun being in front of the camera and performing for others."
For Fong, using the Internet was the key to finding a great job. "You can find almost anything that you'd like to do online," she says. "And you can respond to a bunch of ads online in the time it takes to mail your resume to just a few places."
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Although not everyone's research will lead to such a high-profile gig, career information for any student is only a few mouse clicks away.
Maybe you'd like to learn more about careers worth pursuing in the future. Or perhaps you want to compare salaries and educational requirements for different fields or land a part-time job or an internship. "Many of the things you need to find and get a job are on the Internet these days," says Tim Driver, senior vice president of Salary.com. "You can search job postings, research companies, send in applications, and find out how much you should be paid."
Driver notes that the Internet offers particularly exciting possibilities for summer employment. "Teens are no longer confined to working the register at the supermarket down the street or slinging chowder at the local clam shack," he says. "You can now apply for a job at a national park in Montana from a computer in Boston."
* How do I get started?
The first step in finding career information online is to have a good idea of what you are looking for. Before using a search engine such as Google or Yahoo, take a few minutes to jot down notes on just what you're seeking.
"When using search engines, be very specific in your wording," says Brenda Fabian, director of the Center for Career Services at Susquehanna University in Pennsylvania. For example, if you are looking for a job, use specific terms in your research. "Don't just type in jobs," Fabian recommends. "Instead, enter retail jobs Philadelphia or summer resort employment. You'll have less information to sort through."
If you're interested in a specific employer, you can either type in the company's name followed by .com (if it is a for-profit company) or .org (if it is a nonprofit organization) or conduct a Web search using the company's name. To explore job opportunities with Kroger grocery stores, for example, you could guess that its URL is www.kroger.com (it is) or conduct a basic Web search with Kroger as the search term. Are you searching for general information about a career as an accountant? Key in accounting and career to begin your quest for information.
Many universities have career centers with useful links to career development sites. Those sites can be great starting points for research.
Although organizations' Web site designs vary, you'll find common elements. Most sites have sections titled Employment, Jobs, or Careers. Job listings and career information can sometimes be found in the About Us section on a company's or an association's home page.
* How do I know whether a site's information is reliable?
In navigating the online world, use caution. The Internet has a wealth of information, but not all of it is helpful or accurate. "Anyone can put just about anything on the Web, even completely false information," says Susan Cheng, a library director at DeVry University. "So be sure to evaluate sites carefully before relying on them."
Here are a few strategies you can use to evaluate a Web site.
Determine who is responsible for the site. Information provided by a business or a professional organization is generally more reliable than what you'll find on someone's personal Web site. Sites offered by government agencies (.gov), nonprofit associations (.org), and educational institutions (.edu) tend to be trustworthy. One useful government site is the Occupational Outlook Handbook, published annually by the U.S. Department of Labor (www.bls.gov/oco). It provides overviews of hundreds of occupations, including job roles, qualifications, and salary information.
Know the site's purpose. Many business sites (.com) are perfectly legitimate and provide valuable career information. However, a few may be more interested in trying to sell something (such as career development books or resume-writing services). So use the same care you would in evaluating any type of advertising. You should be able to find all the resources you need online for free.
Now an 18-year-old freshman at the University of Denver, Fong hosts two music-video shows and a spoof of the online dating scene on ManiaTV! while carrying a full course load. "My job is amazing," she says. "I am getting hands-on experience, plus it's so much fun being in front of the camera and performing for others."
For Fong, using the Internet was the key to finding a great job. "You can find almost anything that you'd like to do online," she says. "And you can respond to a bunch of ads online in the time it takes to mail your resume to just a few places."
Advertisement
Although not everyone's research will lead to such a high-profile gig, career information for any student is only a few mouse clicks away.
Maybe you'd like to learn more about careers worth pursuing in the future. Or perhaps you want to compare salaries and educational requirements for different fields or land a part-time job or an internship. "Many of the things you need to find and get a job are on the Internet these days," says Tim Driver, senior vice president of Salary.com. "You can search job postings, research companies, send in applications, and find out how much you should be paid."
Driver notes that the Internet offers particularly exciting possibilities for summer employment. "Teens are no longer confined to working the register at the supermarket down the street or slinging chowder at the local clam shack," he says. "You can now apply for a job at a national park in Montana from a computer in Boston."
* How do I get started?
The first step in finding career information online is to have a good idea of what you are looking for. Before using a search engine such as Google or Yahoo, take a few minutes to jot down notes on just what you're seeking.
"When using search engines, be very specific in your wording," says Brenda Fabian, director of the Center for Career Services at Susquehanna University in Pennsylvania. For example, if you are looking for a job, use specific terms in your research. "Don't just type in jobs," Fabian recommends. "Instead, enter retail jobs Philadelphia or summer resort employment. You'll have less information to sort through."
If you're interested in a specific employer, you can either type in the company's name followed by .com (if it is a for-profit company) or .org (if it is a nonprofit organization) or conduct a Web search using the company's name. To explore job opportunities with Kroger grocery stores, for example, you could guess that its URL is www.kroger.com (it is) or conduct a basic Web search with Kroger as the search term. Are you searching for general information about a career as an accountant? Key in accounting and career to begin your quest for information.
Many universities have career centers with useful links to career development sites. Those sites can be great starting points for research.
Although organizations' Web site designs vary, you'll find common elements. Most sites have sections titled Employment, Jobs, or Careers. Job listings and career information can sometimes be found in the About Us section on a company's or an association's home page.
* How do I know whether a site's information is reliable?
In navigating the online world, use caution. The Internet has a wealth of information, but not all of it is helpful or accurate. "Anyone can put just about anything on the Web, even completely false information," says Susan Cheng, a library director at DeVry University. "So be sure to evaluate sites carefully before relying on them."
Here are a few strategies you can use to evaluate a Web site.
Determine who is responsible for the site. Information provided by a business or a professional organization is generally more reliable than what you'll find on someone's personal Web site. Sites offered by government agencies (.gov), nonprofit associations (.org), and educational institutions (.edu) tend to be trustworthy. One useful government site is the Occupational Outlook Handbook, published annually by the U.S. Department of Labor (www.bls.gov/oco). It provides overviews of hundreds of occupations, including job roles, qualifications, and salary information.
Know the site's purpose. Many business sites (.com) are perfectly legitimate and provide valuable career information. However, a few may be more interested in trying to sell something (such as career development books or resume-writing services). So use the same care you would in evaluating any type of advertising. You should be able to find all the resources you need online for free.
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