RCHC Community Project Abstracts

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The Strawberry Wilderness Community Clinic: A Patient Centered Medical Home for the people of Grant County?
Date of project: 10/12/2009

The Patient Centered Medical Home (PCMH) is a model of care gaining support in the primary care community as a delivery system focused on coordinated, comprehensive health care and the patient experience. As health care reform in this country pushes to make improvements in quality and safety, the PCMH may become an ever-more-relevant piece of the healthcare puzzle. However, transitioning to this model from the current fee-for-service model requires time, money, and a coordinated effort by all levels of staff to change some of the fundamental pieces of the health care delivery system. Is this transition feasible in a small, rural practice like the Strawberry Wilderness Community Clinic (SWCC) in John Day, Oregon? How well does SWCC already provide a PCMH for its patients? What are some of the barriers that SWCC (and presumably other small rural health clinics) face in providing this type of health care and what are some ways in which SWCC can move toward providing a PCMH in the future? This study attempted to address these questions via interviews with clinic staff along with a survey developed to assess patient satisfaction. Results of the interviews were qualitative in nature and produced information regarding quality measures, information technology and practice organization at the SWCC. The patient survey generated 25 responses, producing quantitative information on the patient experience and access to healthcare. It was determined that SWCC provides some aspects of a PCMH, mostly with regards to the patient experience, but struggled to meet most of the quality measures associated with providing a PCMH. The biggest barrier appeared to be a lack of trained staff to do data collection or analysis on the quality of health care and health outcomes at SWCC. There were many suggestions for future improvement.

Optimizing Care of Chronic Pain Patients in a Rural Primary Care Clinic
Date of project: 8/3/2009

Treatment of chronic pain can present one of the most challenging scenarios in medicine – both for clinicians and patients alike. Managing constant prescription refill requests and sometimes frustrated patients can be taxing on clinic staff and providers, while communicating the subjective experience of pain can be emotional for patients whose pain may often go untreated or under-treated due to historical sensitivity about prescribing narcotic medications. Further complicating this delicate relationship between patient and clinic is the increasing prevalence of prescription drug diversion and abuse, particularly among American youth. This project investigated current trends in the management of chronic pain at the clinic and community level, gathering information from medical literature, local clinic staff, surveys of chronic pain patients, and interviews with key community role players. A summary of recommendations was developed to assist local providers in optimizing the care they provide to patients with chronic pain.

Utilization of the POLST Form in Long Term Care Facilities in John Day, Oregon
Date of project: 6/29/2009

The POLST (Physician Orders for Life-Sustaining Treatment) has helped translate patient wishes into tangible and specific Physician’s orders and helps to ensure that patient wishes during the dying process will be honored across various care settings. The use of the POLST form has increased dramatically since it was first developed at OHSU in 1991. Data from study done in 2004 showed that approximately 96% of Nursing Homes in Oregon used the POLST for around 50% of their residents. Furthermore, another study in Oregon indicated that rural areas are more reluctant to use the POLST forms and usage was less in these areas. My goal was to study the utilization of the POLST form in all of the long term care facilities in and around John Day, Oregon. I reviewed charts at Blue Mountain Nursing Home, Valley View Assisted Living, Country Spice Residential Care Facility and Blue Mountain Hospice. I also interviewed the directors of Elderberry House and Golden Heritage which are both adult foster care homes in John Day. I found that 100% of residents at these facilities have a POLST form in their charts and staff are well aware of the POLST and the patient’s wishes. Directors and staff at these facilities were also educated regarding the POLST Registry which is a way for emergency personnel to access the POLST when the actual form is not available. Further exploration needs to be done to assess the utilization of the POLST form among dying patients at home who are not living in a long term care facility and who are not involved in Hospice.

Inactivated Influenza Vaccine Rate and Implications in Diabetic Patients in John Day, Oregon
Date of project: 4/27/2009

Flu vaccination is an important preventative focus of diabetic care. Deaths and hospitalization from influenza are uncommon among the general population. However, diabetes puts people at higher risk for severe flu illnesses, secondary complications and death. Given the high prevalence of diabetes and the development of the diabetic questionnaire in John Day in November 2008, I would like to use this opportunity to understand whether the influenza vaccination rate is improving with the utilization of the questionnaire. The project is designed as a retrospective study for the inactivated influenza vaccination status on diabetic patients seen for the last two years in Blue Mountain Hospital, Strawberry Wilderness Community Clinic. A total of 307 diabetic patients were selected for the study. The result shows the rate of influenza vaccination increased from 30% in 2007 to 38% in 2008.

Current use and capacity for colorectal screening by colonoscopy in Grant County, Oregon
Date of project: 3/16/2009

Colorectal cancer incidence and death is largely preventable by screening. Colonoscopy is a particularly compelling screening modality for frontier communities, but capacity may not exist in all these communities to increase screening via colonoscopy given limited access to resources and physicians. A study was conducted in the frontier communities of Grant County, Oregon to determine existing colonoscopy uptake rakes and screening capacity.

Incidence of Caesarean Deliveries In Rural and Urban Areas: Do our small towns have the answers to solve the bigger issue?
Date of project: 2/9/2009

Caesarean births are rising in the US and have been for the last decade. There are likely many contributing factors, and just as likely there is no easy answer for how to reverse this trend. While we may look to patient preference, physician discretion, and changing medical standards for a part of the explanation, this paper attempts to break down this growing problem to see if there are parts of the country that are effected more than others. In the town of John Day, Oregon, the rise in caesarean deliveries has grown high above the national average and it is even higher still above Oregon’s urban center of Portland. But while the effects of this trend towards caesarean delivery is more apparent in this rural setting, the town of John Day may also be able to show us a clue to stopping this rise. In the final year of data analysis, 2007, the town saw a rapid decline in the incidence of its caesarean deliveries, interestingly enough this year also marked the highest number of deliveries, by caesarean or vaginally. While this paper does not leave its reader with the answer for how to solve the rise in caesareans, it does offer the next step in researching how John Day was able to buck the trend.

Patient Perceptions of Rural Surgery: Can John Day's Blue Mountain Hospital compete with larger outside hospitals?
Date of project: 12/29/2008

CONTEXT: Rural residents frequently have decreased access to surgical services. Consequences of this situation include increased travel time and financial costs for patients. There are also economic implications for hospitals as they may lose revenue when patients leave the area in order to obtain surgical services. Rural communities vary in size and distance from more populated centers. Since rural hospitals are located in varying types of rural communities, they likely differ with regard to the provision of surgical care. PURPOSE: To describe the differences between hospitals located in smaller versus larger rural areas regarding the provision of surgical care. METHODS: A 12-item survey instrument based on one previously used in a pilot study was mailed to a national random sample of rural hospital administrators (n = 233). Rural location was determined using rural-urban commuting area codes. FINDINGS: One hundred and eleven surveys were received, yielding a 48% response rate. Hospitals in larger rural areas had an average of 9 surgeons compared to 1 at hospitals in smaller rural areas. More administrators at hospitals located in larger rural areas viewed the ability to provide surgical care as very important to the financial viability of their hospital. CONCLUSIONS: Among rural hospitals located in communities of varying sizes there are significant differences in how surgical services are delivered and the financial importance of providing surgical care. Administrators at hospitals located in larger rural areas, more than in smaller ones, report financial reliance on their ability to offer surgical care and have significantly more resources available to do so.

Postnatal and Well-Child Care in Grant County
Date of project: 9/8/2008

Grant County is a rural area made up of 7250 residents and is primarily agricultural. The four physicians in John Day provide the primary care, obstetrics, gynecology and emergency care for these residents. Some have been under the impression that the infants they deliver do not always follow up with preventative care in the clinic. In this six week rural rotation it was also observed that some of the infants coming to the doctor were not always coming in for well-child visits. In a respective study of the two years of deliveries at the Blue Mountain Hospital it was found that 96.3% (n=107) of the infants had follow up visits. However, 11.7% of these had limited follow care, some not having any well-child visits. Grant County has the usual barriers to care, such as lack of insurance, low income, etc., but also had some unique rural barriers as well, including a long commute to see a doctor and a lack of physicians in the area. Recently John Day has lost two physicians and is looking to replace them. The absence or limited follow-up care of 15.0% could create a barrier to providing preventative care to the population in Grant County.

Dead-Man's Curves: Traffic Accident Prevention in Grant County, OR
Date of project: 8/4/2008

Motor vehicle accidents (MVA's) are a significant cause of morbidity and mortality in Grant County, Oregon, and the associated expense costs individuals and the state thousands each year. This study attempted to identify the areas of recurrent traffic accidents in Grant County with the intention to advise the Oregon Department of Transportation (ODOT) to improve roadways as a means of trauma prevention. The student design included conversation with local as well as state police officials, local EMS responders and the Blue Mountain Hospital Trauma staff. In addition, systematic surveys of crash data was performed on the local police crash records, Oregon State Police Crash data, and the Blue Mountain Hospital Trauma database. Two stretches of road in Grant County were identified as being particularly dangerous - Picture Gorge and the OR 395 South of John Day. These two stretches of road have resulted in the activation of the Trauma Response System three times in the past two years, and comprise over 13% of all accidents in Grant County. The results from this study influenced the Blue Mountain Trauma staff to make recommendations to ODOT and to the Oregon Transportation Commission to investigate and improve these dangerous county roads.

Enhancing Diabetes Care
Date of project: 6/30/2008

Diabetes mellitus type II is nearing epidemic numbers in the United States, straining our healthcare delivery system. A complicated disease to manage, diabetes poses a particular problem for rural hospitals and providers who may lack the resources or continuity available to urban patients. Blue Mountain Hospital in John Day, Oregon has addressed the problem of complicated inpatient management, in part, by creating standardized admission and discharge orders for complicated problems. This project aimed to enhance diabetes care at BMH by adding admission and discharge order sets that any provider may use to streamline admission and improve the hospital course. In addition, patient education materials were found and provided. Due to low patient volume, the orders have not yet been used, but received positive feedback from practitioners, hospital staff, and the director of nursing services.

Herbs and Natural Remedies in John Day, Oregon: A Historical Perspective
Date of project: 4/28/2008

The Oregon Department of Parks and Recreation have discovered over 400 herbal and natural medicines at the Kam Wah Chung & Co. museum in John Day, Oregon. It has not previously been identified which of these herbs, if any, are used in modern medical practice, a question frequently asked by museum visitors. Therefore this study aims to answer the following two questions in the form of an educational brochure: 1) Of the remedies that Ing “Doc” Hay and his assistant Lung On used, which are some of the ones still in common use by alternative and western medical providers today? 2) What evidence exists for such use? The design involved interviewing persons directly involved in the museum’s herbal discovery work, researching the historical timeline of traditional Chinese medicine and checking out a scientific catalog of herbs identified at Kam Wah Chung & Co., researching modern-day usage of herbal supplements, and performing an evidence-based review of those in common use. Furthermore, this information was compiled into a visitor-friendly guidebook brochure to be used by the museum staff and handed out to visitors of the museum and interpretive center. In the nearby future, the museum plans to create a hands-on herbal exhibit for which they would offer this brochure to visitors. Finally, Dr. Holland’s clinic office will house copies for patients interested in learning more about the historical and present uses of herbs and the evidence base for such use. As an additional point, the brochure educates the public about the side effects and potential drug-herb interactions of a few traditional remedies.

Childhood Obesity in John Day: Building on Previous Work and Increasing Community Awareness
Date of project: 3/17/2008

Obesity is a growing problem in the United States and its rise has been well documented and publicized as are the long-term health consequences of obesity. During the fall of 2007, during her Rural Community Health Clerkship at the Strawberry Wilderness Community Clinic in John Day, OR, Logan Thomas investigated the prevalence of obesity in elementary schoolchildren in John Day by analyzing height, weight, and sex information and calculating the BMI for all children at Humbolt Elementary School in Canyon City, OR. She found that 32% of children aged 6-11 years in John Day were overweight or at risk of becoming overweight, compared to 19% nationally. She presented this data to school district administrators and helped facilitate discussions of options for future action to address the problem of childhood obesity in their community. In these discussions, the consensus reached by school administrators was that initial efforts should be focused on educating the community. Interest was expressed in developing a handout for parent-teacher conferences to educate parents about the prevalence of childhood obesity in John Day and to give parents some hints and ideas on ways they can help improve their children’s health. I sought to gauge whether there was continued interest in such a handout and coordinate my efforts with those community members already actively working in the issue of childhood obesity. I developed handout for parent-teacher conferences that revisited Logan Thomas’ data and provided tips for parents to help improve their children’s health. It is currently being reviewed by the Grant County School District #3 Superintendent. I also developed a more extensive webpage that included the same information plus additional tips for healthy eating that is posted on the Strawberry Wilderness Community Clinic Website.

Assessing the Current Methods for Managing Hyperlipidemia and Their Effectiveness
Date of project: 3/17/2008

Chronic disease management is a large part of primary care and it can have a big impact on the heath of a population. Hyperlipidemia is one of the more common chronic diseases seen in primary care and it is a major risk factor for cardiovascular disease and stroke. Coronary heart disease is the leading cause of death in this country. Studies have shown that optimal management of patients with hyperlipidemia is essential to decreasing the risk of cardiovascular disease. The goal of this study was to assess the current methods for managing hyperlipidemia in one rural family practice clinic and their effectiveness. The design was observation of clinical practices, interviews with clinic providers and random chart reviews of twenty-five patients with previously diagnosed hyperlipidemia. The findings indicated that lipid levels were fairly well controlled with the current strategies. Areas for improvement included regular patient follow up and management of coexisting cardiovascular risk factors. A standardized form was created to be both a clinical checklist as well as a tool for documentation. It is expected that this document will help improve overall management and facilitate simple and comprehensive documentation.

Non-urgent Use of Hospital Emergency Services in Grant County, Oregon: The Impact of Primary Care Physicians Fleeing Rural America
Date of project: 2/11/2008

Primary care physicians' covering the Emergency Department is almost exclusively seen in rural health settings. While these physicians rarely encounter problems of overcrowding and prolonged patient wait times often seen in larger cities, several issues arise that are somewhat more unique to rural health. One such issue is the direct relationship between the diminishing number of general physicians practicing in rural areas and the resultant overflow of non-urgent patients into the ED. Regardless, it is these same community doctors providing treatment for these patients creating what may be considered a vicious circle. This magnitude of this issue was explored via a questionnaire directed toward patients visiting the rural Blue Mountain Hospital Emergency Department in John Day, Oregon during a three-week period between February 2008 and March 2008. The results of this study showed that nearly 45% of all patients presenting to the ED during this time had initially attempted to address their health care needs in the primary care setting. These patients also encounter 30% higher costs for health care than their counterparts receiving care via their regular physician.

Use of email in a rural family practice setting: a strategy to meet increasing demand on limited health care resources in John Day, Oregon.
Date of project: 2/11/2008

The challenges created by physician shortages in rural communities require creative solutions that maximize available resources. Previous studies have demonstrated that Internet technology such as email, electronic medication refills, and web consults has the potential to improve efficiency and increase productivity among family practice clinics. It has also been shown that a majority of patients use the Internet and are interested in electronic communication with their physician. This study attempted to determine the number of patients in a family practice clinic in rural John Day, Oregon that have access to the Internet and are receptive to emailing with their doctor. Methods included a survey and informal interview of a convenience sample of patients at the clinic about their use of the Internet and attitude toward using this medium to interact with their doctor. Information about gender, age, and place of residence was also recorded. Fifty-nine percent of patients sampled did not use the Internet and were not interested in any form of Internet technology to communicate with their physician. This attitude was found entirely among elderly patients who cited their inability to navigate the web and lack of understanding of its potential benefits as reasons for not using the Internet. This survey showed that patients in John Day do not have enough interest and fluency in Internet technology to make this form of communication a viable option at this time.

Childhood Obesity Prevalence in John Day: A Project of Data Collection and Dissemination.
Date of project: 10/15/2007

With more data and continued discussion of health effects, the obesity epidemic has become perhaps the largest health problem facing the American population today. Despite its prevalence and its proven health consequences, many communities continue to believe that obesity is not an issue. This belief is not easily altered. This study was designed to collect height and weight data from all children attending Humbolt Elementary School, calculated BMIs for each child, and then graph them on the CDC growth charts to determine the number of overweight and at risk of being overweight children in each age and gender category. On average, 32% of children in John Day are either overweight or at risk of being overweight. Research into national data, rural data, and rural Oregon data was done to provide context for the data collected in John Day, and this was presented together to the school district administration. After the presentation, a discussion of possible ways in which schools can enact change and various options for funding these changes was discussed with the school district administration. The end result of the project led to an increased awareness of the extent of the obesity issue in John Day and an increased interest in enacting change within the community to address this issue.

Analysis of average body weights in selected pediatric populations between 1997 and 2007 in John Day, OR
Date of project: 10/15/2007

The number of children in the United States who are overweight, or at risk of becoming overweight has reached epidemic proportions. Annual obesity-related costs in 6-17 year-olds exceed $127 million per year and project to far exceed this value in the future as these children mature into adults as obesity is a key risk factor for the development of many adverse health conditions including: hypertension, dyslipidemia, Type 2 diabetes, cardiovascular disease, sleep apnea and orthopedic pathologies. Increased consumption of foods high in calories and fat combined with decreased amounts of physical activity are environmental factors identified as key contributors to this obesity epidemic. As these environmental factors have become more prevalent in rural communities, the effect upon the body weight of children in these communities is a concern. The goal of this project was to evaluate changes in the average body weights of 5-6 year-old children, 9-10 year-old children and 13-14 year-old children in 1997, 2002 and 2007. The results of this study show that the weights of 5-6 year-old children in John Day, OR have significantly increased over the past 10 years and that the weights of both 9-10 and 13-14 year-old children are trending upwards. These results of this study were discussed with the medical community with the goal that increased awareness of this trend will lead to improved screening and implementation of preventative measures.

Reminders to providers and parents as an intervention to address below-goal immunization rates
Date of project: 9/10/2007

Rates of immunization at the Strawberry Wilderness Family Clinic were compared to those of other rural providers in Oregon and found to be lower than expected. The clinic staff was consulted to identify aspects of the immunization protocol which needed improvement. This lead to 1) creating a reminder to providers in the clinic EMR for children past due on immunizations and 2) assembling postcards to be sent to parents of past due children. These methods have been shown in the literature to improve immunization rates. Impact of these changes will be determined in future reviews of the clinic's rates. Additional interventions in clinic protocol, such as standing orders, and programs, such as Oregon AFIX, should be employed if rates continue to be below goal.

Evaluation of Childhood Immunization Delivery in John Day, OR
Date of project: 9/10/2007

Childhood immunizations are an important public health initiative in preventing what were once common causes of childhood morbidity and mortality. Rural children may face increased barriers to immunizations due to living in medically underserved areas. In John Day, OR, the Grant County Health Department provides and tracks the immunizations for all of the patients seen by Dr Holland. The objective of this study was to evaluate immunization delivery, compare records between the clinic and the health department, and suggest strategies by which immunization rates can be improved. An analysis of all of Dr Holland’s patients aged 19-35 months (22 children) was conducted using patient charts and health department immunization records to determine immunization status at 24 months, as well as percentages of late starts and missed opportunities. These results were compared with similar data from January 2006 for Dr. Holland’s clinic recently released from the Rural Oregon Immunization Initiative (ROII). The percentage of children up to date with the recommended series of 4 DTaP; 3 IPV; 1 MMR; 3 Hib; 3HepB; 1 Varicella was 72%, which is an improvement from the rate of 57% found by the ROII. The percentage of children up to date by 35 months was 77%, that of late starts was 18% and of missed opportunities 9%. While these rates are all improved from the ROII data from 2006, they are not yet reaching the Healthy People 2010 goal of 80% or better coverage. The rates could be improved by decreasing the percentages of late starts and missed opportunities, by improving communication between the health department and the clinic, and by addressing parents concerns and fears about immunizations. The clinic will begin using the ALERT immunization registry to better track immunizations and remind patients of due vaccines. All children found by this project to be behind on their vaccines were notified and encouraged to complete the series.

Hepatitis C and Associated Methamphetamine Abuse in Grant County, Oregon. Is it a Problem?
Date of project: 8/6/2007

Hepatitis C (HCV) is a chronic blood born disease that can lead to long-term disability and death. It is most often transmitted through injection drug use. In Oregon methamphetamine is often the drug of choice for injection drug users, and there is significantly higher rate of HCV infection among this population. Methamphetamine is considered a major problem throughout Oregon in rural, suburban, and metropolitan communities. Rural Grant County is no exception to this, and it has a population of people addicted to the drug. However, when compared to neighboring rural Umatilla County it appears to have a smaller population of methamphetamine users with a lower incidence of HCV infection. This is most likely due to the fact that few people in Grant County inject the drug, but instead tend to smoke it or snort it. Also, the smaller population size of Grant County may make it easier for law enforcement officials to target drug users. However, county residents interviewed feel that methamphetamine use does pose a threat to their community. Also, if users switch from current methods of use to injecting the drug, the HCV infection rate would be likely to increase.

Establishing a web home for the Strawberry Wilderness Community Clinic
Date of project: 7/2/2007

Internet usage in rural areas is rapidly increasing. As this occurs, more and more rural businesses are establishing online web presences, allowing them to interact with current customers and reach potential new ones. In the health care arena, the ability to attract patients is limited by physical distance, but the Internet can also be used to disseminate important information both about the clinic and about the health care provided. This project is designed to establish a web home for the Strawberry Wilderness Community Clinic, for which patients will be able to find out information about the services provided by the clinic, common health problems and procedures performed, and interact with clinic staff by email or by phone.

Traumatic injury in off-road vehicle use in rural Oregon
Date of project: 4/30/2007

BACKGROUND: Rural MVA mortality is twice that of urban mortality. Pediatric ATV injuries are increasing, and new legislation is being presently debated. The study evaluated the risk of ATV injury in pediatric versus adult populations in the Blue Mountain Hospital service area over 33 months. METHODS: Emergency visits at BMH, selected by E-code E810-825. Outcomes were incidence and odds ratios. RESULTS: ATV’s accounted for 23.9% of the MVA patients. 9.4% of non-ATV injured patients and 22. 4% of ATV injured patients were pediatric. Risk factors for ATV injury include age < 16 (OR 2.85, p = 0.008), male gender (OR 3.18, p = 0.001), and white race (OR 3.408, p = 0.039). Risk of head or neck injury higher in ATV use (OR 2.637, p = 0.004). CONCLUSION: Age restriction as well as requirement of helmets, both currently proposed in the legislature, may decrease the burden of ATV-related injury on the rural pediatric population.

Community-based health insurance: an innovative solution for John Day’s un- and under- insured.
Date of project: 3/19/2007

The community of John Day, Oregon has a number of un- and under-insured citizens who pay large amounts out-of-pocket on healthcare. Many wait to see an MD until they are sick and do not seek preventive care. They represent the fastest-growing group of uninsured in America: the uninsured who are employed and do not qualify for categorical eligibility for public programs (Medicare, OHP). Patients of the Strawberry Wilderness Community Clinic were surveyed regarding their demographics, insurance status, and opinions on a potential new healthcare plan. This plan, known as community-based health insurance (CHI) is used in developing countries and involves patients contributing a small amount of money per month ($10) to a risk-pool which can then defray healthcare costs among the community. There are certain limitations, and for John Day, the initial plan would only cover the cost of a clinic visit (no meds/labs). Nearly all un- and under-insured surveyed would be interested in this plan and willing to pay the proposed fee. Their concerns were about overuse of the system by a few. Physicians surveyed were all interested in the program, but had serious concerns about cost and too few patients for it to be economically feasible. Momentum for the plan would a barrier to implantation, as healthcare in the US seems to be “stuck” with a lack of innovation for new ways to ensure access. CHI would be one such way.

Breast Cancer Patient Resources in Grant County, Oregon.
Date of project: 2/12/2007

Breast cancer is a major medical concern for women in the United States. Women currently are thought to have about a 1 in 7 lifetime risk of developing breast cancer. This means that even a small community such as John Day, Oregon in rural Grant County likely has many women who have dealt or are dealing with a diagnosis of breast cancer. The goal of this study was to attempt to determine if there is a need for breast cancer patient resources in Grant County and if so what resources are currently available to meet this need. Although there is not an oncologist in Grant County or a site for chemotherapy infusion or radiation, there are still likely many breast cancer patients/survivors living in the area who may need support and resources outside of those provided when going out of town for treatment. The design of this study was observation of materials available at health care provider clinics as well as interviews of local health care providers and breast cancer patients and survivors. The final outcome of this project was to develop a database of contacts for local resources as well as to obtain a handout of national resources for the local health care provider offices.

Breast Cancer Screening in Grant County, OR
Date of project: 2/12/2007

Breast Cancer is one of the most common malignancies in the United States today. In fact, it is the most common non-skin cancer. It is also the second most deadly type of cancer behind lung cancer. While the disease is not preventable, it is highly treatable as long as it is caught at an early enough stage. Screening for breast cancer has been standardized and there are screening guidelines and goals defining the percent of the population that need to be screened to meet these criteria. In my clinical experience in John Day, OR, I noted that many patients were not up to date with their breast cancer screening. The goal of this project was to define the current screening rate in Grant County and identify areas for improvement. I found the overall rate to be lower than both the state and national average. There were several identified barriers contributing to this low level of screening, the most obvious being lack of information at the point of service. At the conclusion of this project I supplied updated and more visible information for patients regarding breast cancer screening.

When are Thrombolytics Indicated?
Date of project: 1/1/2007

The issue of when and when not to use thrombolytics in rural community hospitals continues to exist. This issue is propagated by an increase in the use of percutaneous intervention in urban areas as well as the increasing frequency of immediate inter-hospital transfer to PCI capable institutions in the case of ST-Elevation Myocardial Infarction. This change in the standard of care in urban settings has caused a perceived lack of need for extensive education in the use of thrombolytics and a resulting deficiency in training at urban care centers. This alteration then disturbs health care administration at rural community sites due to consults from care centers where thrombolytics are rarely used. The use of protocols in community hospitals addressing the proper use of thrombolytic medications when indicated may prevent the under use of this live saving treatment.

Recruitment and Retainment of Rural Physicians: the difficulties found in the Frontier community of Grant County, Oregon.
Date of project: 1/1/2007

Recruiting and retaining physicians in rural areas is an ongoing problem in the United States today. Physicians are trained in urban areas and often prefer to remain there to practice creating difficulty in recruiting to rural communities. If a physician does choose to practice in a rural setting they often feel isolated and overworked and usually remain for only a short time. This report analyzes the recruitment process of the Blue Mountain Hospital and a private clinic in Grant County, Oregon and identifies the difficulties in recruiting and retaining physicians in that area. Data were gathered from journal articles and interviews with local physicians and the hospital administrator. Grant County uses a variety of physician recruitment firms and word of mouth advertising, although in the last five years three of the new doctors have come through the Oregon Area Health Education Center. In the last eighteen years Grant County has had sixteen different physicians, each of them remaining only four years on average. In addition to lack of medical student exposure, local physicians identify various lifestyle and professional issues as barriers to recruiting and retaining physicians. I attempt to offer solutions to these issues including more selective recruiting and improved strategies to expose medical students to rural medicine

Mental Health Resources in Grant County, Oregon: Current Status, Recent Changes and Accessibility to Patients
Date of project: 10/16/2006

In 1973, the state of Oregon established a regional system of county community mental health programs to provide basic mental health services to all residents and alternatives to hospitalization for certain residents needing higher levels of mental health care. Since then, the movement of deinstitutionalization and the Oregon Health Plan, have contributed greatly to the number of people who seek care at county mental health programs across the state. Grant County’s community mental health program, the Center for Human Development (CHD), located in John Day, Oregon, is the only resource providing solely mental health services for the county’s 7,800 residents. Interview with CHD administrators identified the following challenges: lack of and difficulty retaining trained mental health professionals at CHD, ever decreasing funding and reimbursement for services, social stigma regarding mental health care, and difficulty perceived by CHD with interfacing with the existing family practice clinics in John Day. Additionally, the Strawberry Wilderness Community Clinic (SWCC) family practitioners have difficulty making successful referrals to CHD, getting progress reports from CHD on referred patients, and staying current in diagnosis and treatment of less common psychiatric conditions. Therefore: 1) an informational patient handout about CHD was prepared for distribution to SWCC patients, 2) conversations between CHD and SWCC were initiated to establish designated SWCC space and time for a CHD counselor to see referral patients, and 3) conversation was initiated to establish a designated family practitioner who could be contacted for medication prescription in the event of psychiatric crisis.

Medical Management of Chest Pain in John Day, Oregon: Development of a Standing Order Form.
Date of project: 9/11/2006

I was able to create a standard admission form that is clear in its wording, directs physicians and nurses towards up-to-date diagnostic testing and treatment strategies. Based on my interviews with the physicians, nurses, and ancillary healthcare professionals practicing at the Blue Mountain Hospital, this form will be useful and used by the physicians there. This has the potential to positively impact not only physicians and staff at Blue Mountain Hospital, but also its patients as studies have shown that effective standardized orders lead to more consistent and higher quality care. As chest pain is one of the most common diagnoses in hospitals across the nation, my form has the potential to make a sizable impact in the John Day and Grant County community.

Access to Abortion Resources in John Day, Oregon
Date of project: 8/7/2006

Current abortion trends indicate that the availability of providers is declining in rural areas. In 2000, 78% of all Oregon counties had no abortion provider. As a result, women must travel longer distances, overcome economic barriers and risk exceeding gestational limitations to terminate their pregnancy. John Day, Oregon is no exception to this trend. Six physicians, 1 NP and 1 PA were interviewed regarding how they provide resources to women seeking abortions. Although no providers exist, 87.5% of the health care workers said they would refer women for an abortion if she asked. In the case of rape or incest, 62.5% said they would “always” include termination in their discussion with the patient. In the past year, the 5 referrals that have been made were from the two female providers. Due to concerns over confidentiality and negative repercussion from the community all agreed that a local abortion provider would not be accepted or used effectively. For rural women, the drawbacks of leaving one’s community, including higher risk of exceeding gestational limitations and money, do not appear to outweigh benefit of anonymity.

Management of Mental Health Emergencies in John Day, Oregon
Date of project: 8/7/2006

Resources for appropriate treatment of mental health crises are limited in rural communities. The purpose of this project is to assess the infrastructure and clinical support for managing mental health crises in John Day, Oregon. This investigation included discussion with health professionals from the Blue Mountain Hospital and within the Grant County Department of Mental Health. These organizations provide care to the population of Grant County, as well as any patients presenting to the Blue Mountain Hospital Emergency Department. In addition to discussion with health care providers, literature searches were performed with the goal of assessing the strategies currently used by other rural communities for providing psychiatric care. In the course of this investigation, it was identified that the lack of a psychiatric hold unit within Grant County creates a particular challenge for managing patients in mental health crisis. Therefore, the discussion of this investigation will focus on this particular need and explore possible approaches to addressing the problem.

Hyperlipidemia in John Day, OR: An Assessment of Follow-Up and Management
Date of project: 7/3/2006

BACKGROUND: Although mortality from heart disease has steadily declined since 1980, it still remains the leading cause of death in the United States and the second leading cause of death in Oregon. Of the 685,089 deaths caused by heart disease in the US, 70% were due to ischemic heart disease. Correlation between certain risk factors and premature coronary heart disease (CHD) has been markedly established, and about 80-85% of individuals with CHD possess one or more of the four conventional risk factors: cigarette smoking, diabetes, hyperlipidemia, and hypertension. Current data suggests that optimal control of hyperlipidemia with appropriate follow-up can significantly reduce an individual’s risk for cardiovascular events, and proper management in patients with CHD can significantly decrease cardiovascular events, cardiovascular mortality, and overall mortality. OBJECTIVE: To assess whether or not the stated goal of six-month cholesterol screenings for previously identified hyperlipidemic patients is being met; and to determine if treatment plans accomplish the desired goal of lowering cholesterol. METHODS: A random chart review of patients with hyperlipidemia in Dr. Holland’s practice was performed. CONCLUSIONS: Because there was a significant decrease in total cholesterol, LDL, and triglyceride levels in patients with hyperlipidemia, therapeutic management of this disease in Dr. Holland’s clinic is adequate. However, there was an overall decrease in HDL, which is less than desirable. Also, the stated desired goal of six-month follow-ups for hyperlipidemic patients is not being met but implementing a patient reminder system could increase follow-up.

Charting Chronic Pain in Grant County
Date of project: 5/1/2006

In the primary care practice of Dr. Robert Holland and Dr. Russell Nichols in John Day, Oregon, chronic pain visits occupy an average of 4-5 visits per day and these patients see the doctor 2-3 times more frequently than other chronic pain patients. The age distribution of Grant County is becoming top-heavy, with those >65 years old comprising 17.1% of the population, nearly five percent greater than the national average. Additionally, the number of manual laborers and individuals participating in outdoor activities that are tough on their bodies is commonplace in this population. Hence, the development of a standardized form for charting frequent pain management visits for musculoskeletal, neuropathic, fibromyalgia, longstanding post-surgical pain, and chronic narcotic use can save both time and money for a busy primary care practice. The average cost savings per physician in the practice from using a form rather than dictating progress notes from chronic pain visits is approximately $772 per year. Efficacy of this form is likely to be seen more in a rural setting due to the fact that there is little turnover of the population and few doctors, so there is greater longitudinal data collection. Optimal use of the form will allow for concise, long-term data collection and more focused pain management strategies that improve both the patient and physician satisfaction.

High-Risk Obstetrics in Grant County, Oregon. (Nearest NICU: 151 miles)
Date of project: 5/1/2006

High-risk obstetrical care can be scary, for both patient and doctor, no matter where it takes place. It can become even scarier, though, in a rural environment such as Grant County, OR, which is more than 2 hours by car from the nearest NICU. Occasionally during rural high-risk pregnancies, the decision must be made whether and when to refer high-risk patients to a more urban setting. This decision is an important one: not only might it affect the health of the mother and her offspring, but it might also impact the cost of malpractice insurance, thereby potentially affecting the entire community. For this project, I initially planned to use a literature search to identify indications for referral of rural high-risk obstetrical patients to an urban setting. I thought that I would discover several sets of guidelines about when referral to urban centers, or at least to obstetricians, is indicated. I planned to use these guidelines to develop a set of criteria to help doctors and patients in Grant County make their decisions. However, an extensive literature search did not reveal any such existing criteria. Next, I interviewed both doctors and pregnant women in Grant County. I have come to the conclusion that the decision of whether to transfer care to the city is a highly variable one and depends entirely on the comfort level and belief system of the patient and doctor who are making the decision. Each choice to stay or to go is a unique decision. With this new understanding, I now realize that my initial goal, of developing a set of uniform criteria that would apply to everyone, was not achievable. Rural medicine doctors and patients are not so easy to fit into a flowchart.

Length of patient enrollment on Blue Mountain Hospice, The Physicians who refer patients and suggeted strategies to reduce late referrals
Date of project: 3/20/2006

Blue Mountain Hospice (BMH) opened in August 2005. As with most hospices, one of its main concerns is that a significant proportion of its patients are enrolled for only a matter of a few days. The concern is that as a result, many of these patients and their families may not have time to fully benefit from the services hospice has to offer. The goals of this project were to 1) further the degree of mutual understanding between the physicians of Grant County referring patients to BMH and the staff of BMH; and, 2) provide recommendations and resources to both the physicians and BMH on possible strategies which may help to reduce late referrals. To accomplish these goals, the seven Grant County physicians were surveyed on hospice referral history, training and attitudes towards hospice, barriers to timely referral and interest in hospice related continuing education. Files of patients referred to BMH were then reviewed to characterize the population referred. Results indicated that referring physicians generally believe they are well trained in hospice, express positive attitudes towards hospice and are moderately interested in continuing education. Of the 15 patients enrolled with BMH to-date who ultimately either died on hospice (12) or were discharged (3), the median length of enrollment was 6.5 days and two patients were enrolled for only one day. Recognizing that certainly not all of the late referrals could have reasonably been avoided, recommendations and associated resources are provided to both BMH and the referring physicians with the intent that the proportion of late referrals can, over time, be reduced and more of the patients and their families can fully benefit from the unique services offered by hospice.

Chronic Disease Management in Grant County
Date of project: 3/20/2006

Problem: Almost half of all Americans have a chronic disease which may lead to extensive morbidity and mortality. Traditionally, diseases such diabetes mellitus (DM), hypercholesterolemia, and asthma are managed on a reactive, acute need basis. Pro-active physician-patient management of these three diseases reduces disease morbidity and mortality. The Grant County Public Health Department is writing a grant for $60,000 to try to improve Grant County’s health care of these diseases. To write and effective grant proposal, the department needs to learn what PCPs in the community are currently doing to manage the diseases and to propose ideas for improvement. Methods: An interview survey was conducted with all of the eight PCPs in Grant County about their current management of DM, hypercholesterolemia, and asthma. They were also asked what challenges they had managing each of these diseases, and what suggestions they had to improve the management of these diseases. Findings: Most PCPs actively monitored DM, many monitored hypercholesterolemia, and only one actively monitored asthma. Poor patient motivation and understanding as well as computer and time limitations were viewed as the largest challenges. Group education classes, such as the group diabetic dietitian class, were viewed as the most helpful resource. In addition, the majority of PCPs think a tickler file would be helpful. Conclusion: Grant County PCPs are currently using a variety of methods to manage DM, hypercholesterolemia, and asthma. All of expressed a desire for improve disease management, mentioning several clinical and community suggestions.

Care of hypertensive patients in John Day, Oregon: Creation of a clinical reminder checklist.
Date of project: 2/13/2006

Hypertension is a medical problem seen by every physician, regardless of his or her specific practice or the type of community they practice in. For physicians in rural communities, it is a diagnosis seen daily. The identification and treatment of patients with hypertension is lengthy, somewhat confusing, and frequently changing. In 2003, the National Heart, Lung and Blood Institute (JNC7) created a new treatment algorithm for hypertensive patients. This study attempted to determine whether or not two physicians in a rural family practice clinic in John Day, Oregon were appropriately caring for their patients with hypertension according to the guidelines set forth by the JNC7. The design was a random selection of 20 patients already diagnosed with hypertension, followed by a chart review of these patients. The chart review identified specific areas the physicians were doing well with and a few that they were lacking in. The results of the chart review prompted discussion of the best way to be consistent and complete with the care of every hypertensive patient. It was decided that a checklist with reminders for specific aspects of the physical exam, laboratory tests, lifestyle modifications, and medication review would be created. Two checklists were created including one for the initial diagnosis of hypertension and one for those already diagnosed. These checklists will be placed in the charts of all pertinent patients. It is expected that these checklists will make it easier for the staff and physicians to provide consistent care of their patients with hypertension according to the guidelines set forth in JNC 7.

Evaluation of Diabetes Mellitus Management in John Day, Oregon: Are current standards of care being implemented?
Date of project: 2/13/2006

Diabetes Mellitus is a major medical problem in the United States, affecting 6% of the population. Due to the morbidity and mortality associated with diabetes, standards of care have been designed to help reduce complications of the illness. As part of maintaining its status as an Oregon Federally Certified Rural Health Center, the Strawberry Wilderness Community Clinic (SWCC) is required to perform yearly chart reviews. The purpose of this project was to develop a chart review form for diabetes screening and treatment based on established diabetes guidelines. This form was then used in a chart review of thirty patients, ten from three physicians, to assess if SWCC is currently implementing these guidelines in its practice. Results of the review demonstrated that physicians are meeting guidelines for HbA1c measurement, use of ACE inhibitors, reviewing self monitored blood glucose readings, and checking creatinine annually. Areas of improvement were found to be screening for dyslipidemia and microalbuminuria. The biggest deficits in care were found to be in ensuring that patients received yearly dilated eye exams, visual foot inspection at each visit, comprehensive foot exams annually, and using aspirin therapy in patients > 40 years of age. These results can be used by the SWCC to help design methods to improve deficits in diabetes management and therefore reduce morbidity associated with the disease in their community.

Cholesterol Education in Grant County
Date of project: 1/2/2006

The Strawberry Mountain Wilderness Family Medicine Clinic sees a large number of senior citizens and middle aged patients, many whom have hyperlipidemia. The goal of this project was to create several handouts that address common questions patients have about cholesterol. These handouts discuss what cholesterol is and where it comes from along with the different types of cholesterol. They present guidelines from the NCEP so patients can compare their lab results with recommended levels. They provide methods of lowering cholesterol including diet, exercise and medication. Finally, they will include a summary table of different kinds of fat and how each type affects cholesterol. As part of this project, individuals who participated took a small quiz before and after going over the handouts with the medical student. This quiz was designed as a teaching aid and to help evaluate the effectiveness of the handouts. Nine individuals completed the quiz. Participants preformed moderately better on the post-quiz. Participants reported that they had a better understanding of cholesterol after going-over the information and felt they could share information with their friends and family members. The cholesterol education handouts will stay in the clinic for future use by practitioners.

Diabetes management in John Day, Oregon: a summary of objective measures of diabetes care and the impact of an appointment reminder system on HbA1c testing frequency
Date of project: 1/2/2006

BACKGROUND: The prevalence of type II diabetes is growing nationwide, a trend that includes both urban and rural areas. Intensive diabetes management is a cooperative process between patients and their health care providers: providers have an opportunity to help their patients intervene in an otherwise progressive disease by prescribing medications to improve glycemic control, blood pressure, and cholesterol, screening for complications, and encouraging appropriate lifestyle modifications. Rural settings have the unique challenge of meeting the needs of their patients and complying with complex documentation requirements without the benefits of extra staff or record systems dedicated to diabetes care. OBJECTIVE: The goals of this project were to summarize current objective measures of diabetes care in Dr. Holland’s practice in John Day, OR, assess the management of diabetes before and after the implementation of an appointment reminder system started in July 2003, and create a record system that the nursing staff can use to help improve the documentation of diabetes care. METHODS: A chart review of all patients with diabetes in Dr. Holland’s practice was performed. RESULTS: The chart review identified an average HbA1c of 7.5, blood pressure of 140/74, total cholesterol of 161, triglycerides of 169, HDL of 35, and LDL of 91. The implementation of the appointment reminder system on July 2003 improved the frequency of HbA1c testing. Finally, a database was generated to aid in identifying patients due for an appointment and in documenting vitals, exam findings, and lab values. CONCLUSIONS: Objective measures of diabetes control in Dr. Holland’s practice have been described, and strengths and areas for improvement were identified. Dr. Holland and the nursing staff plan to use the database generated as part of this chart review to aid in reminding patients about their appointments and in documenting diabetes care.

Hypercholesterolemia and hypertriglyceridemia in Grant County, Oregon
Date of project: 10/17/2005

Hyperlipidemia is well-established as an important risk factor in the development of heart disease. Estimates of the prevalence of hyperlipidemia in the US are approximately 1 in 3. Discussions with Grant County physicians and the Grant County Health Department family nurse practitioner indicated that the health care community was unaware of the prevalence of hyperlipidemia in their patient population. Lab data from the annual Health Fair sponsored by the Grant County Health Department, Blue Mountain Hospital and the US Forest Service was reviewed, and individuals with hypercholesterolemia and hypertriglyceridemia were identified. 620 blood draws were recorded, approximately 10% of the population of Grant County. 47% of participants demonstrated elevated cholesterol levels and 27% had elevated triglycerides. These results suggest that hyperlipidemia is a grave health concern in Grant County. A comprehensive educational patient handout addressing screening, prevention and treatment was developed for distribution at the next annual health fair and at the Grant County Health Department. Suggestions for future possible research projects related to this topic are included.

Preventive Medicine and Clinical Preventive Services for Patients
Date of project: 10/17/2005

Preventive medicine and clinical preventive services today are a cornerstone of care for maintaining the health of any population. The activity of health maintenance is conducted by providing periodic health examinations and screening to identify an unrecognized disease or risk factor through history taking, physical examination, laboratory test, or other procedure that can be applied in short order. Screening tests can rapidly sort out apparently well persons who have a disease or a risk factor for a disease from those who do not and therefore are an important part of preventive medicine. However, many patients are unaware of or misunderstand the purpose of these preventive medicine measures which can ultimately lead to higher rates of morbidity and mortality if not accomplished or may even cause distrust in the current health care system due to the perception that a test or procedure is unnecessary. This project was created to help patients gain a better understanding of preventive medicine services. It provides a patient handout that describes the purpose of preventive medicine and lists medical conditions and screening options according to specific patient groups. This is intended to aid in both patient education as well encourage patients to ask questions and enable them to become more directly involved in the decision-making process that affects their health and health care. The preventive services described are compiled from the current U.S. Preventive Services Task Force guidelines and recommendations for clinical preventive services from the American Academy of Family Physicians.

Healthcare for the Underserved Population of Grant County.
Date of project: 9/12/2005

Rural areas in Oregon tend to have large percentages of patients on Medicare or Medicaid than do larger more metropolitan areas. Grant County Oregon is served by four family doctors who not only see patients during clinic hours, but are on call 24 hours a day, seven days a week to staff the emergency room at Blue Mountain Hospital, the only hospital in the county. Grant County has a very vulnerable and needy population in terms of the ability to access and pay for medical care. 25% of people live at or below the poverty level, and 60% live at or below 200% of the poverty level. More than 60% of the patients who are treated at the Blue Mountain Hospital are on either Medicare or Medicaid. According to the US Census Bureau, about 18% of the population is living with some sort of disability. This situation is a reality in Grant County. Medicare and Medicaid programs only paid about two thirds of the charges that were billed to them from the Strawberry Clinic. This resulted in a loss of $30,000 last year. In March, 2005, the clinic became a Rural Health Clinic in an attempt to continue caring for the rural community.

Methamphetamine use in Grant County: Development of a patient handout to increase methamphetamine treatment.
Date of project: 8/8/2005

Methamphetamine use continues to be a growing and seriously problem in the United States, with rural areas being affected particularly heavily. This project was designed to increase the use of treatment options by methamphetamines users in Grant County, with the creation of a brochure that is available to patients in the Emergency Room at Blue Mountain Hospital and Grant County Center for Human Development. Before this project, there was a lack of ready information for people who use methamphetamines about their treatment options locally and regionally. The attention grabbing and succinct brochure highlights the reasons why methamphetamine use is harmful, increases insight into the person’s habit, and explains what options are available to help them quit. The handout can be easily altered to accommodate different regions of Oregon and the US, and it is hoped that it will increase the number of people who successfully quit their addiction to methamphetamines.

Health Literacy in John Day, Oregon: A Patient Screen and an Evaluation of Educational Resources
Date of project: 8/8/2005

According to the National Assessment of Adult Literacy (NAAL), forty-six to fifty-one percent of adult Americans are illiterate or functionally illiterate. This adds up to 90 million Americans who cannot synthesize information from complex or lengthy texts and cannot consistently perform quantitative tasks requiring two or more steps. The inadequate literacy skills of Americans are impacting health care in a big way. Numerous studies have linked low literacy with important negative outcomes in healthcare, including higher medical expenses and poorer management of chronic illness. This link between literacy and health has lead to the defining of health literacy as a separate component of functional literacy, and the responsibility to recognize and accommodate patients with low health literacy now lies with health care providers. The problem this project aims to address is that of assessing the health literacy among adult patients of the Strawberry Wilderness Clinic in John Day, Oregon and evaluating resources available both in the clinic and the community for patients with low literacy skills. The results of a health literacy screen of 74 patients using the Rapid Estimate of Adult Literacy in Medicine - revised show that 23% of adult patients in John Day read at or below the 6th grade level and are thus expected to have significant difficulty comprehending most written and oral medical information. There was no significant difference in literacy skills between elderly and young adults. An assessment of written materials available for distribution at the clinic revealed that there were no printed patient education materials designed for patients with low literacy. Finally, local adult basic education resources were found to be more than adequate for meeting the needs of adults wishing to improve their literacy at no cost. However, few people seem to be aware of these education resources.

Are Group Visits for Patients with Type II Diabetes a Feasible Option in John Day?
Date of project: 7/4/2005

The potential morbidity and mortality associated with poorly controlled Type II diabetes mellitus makes patient education a particularly important undertaking in treating this chronic condition. Group visits have been shown to improve HgbAlc and cholesterol levels in patients with diabetes, as well as overall patient and physician satisfaction with care of chronic illnesses. The primary purpose of this study was twofold: to determine whether group visits were a feasible option for the residents of John Day and if so, to put together the necessary information that would facilitate easy implementation of group visits by Dr. Robert Holland. Methods: 1) a focus group was held among select patients with type II diabetes; 2) an interview was conducted with the registered dietitian (RD) to determine whether interdisciplinary support for such visits existed. 3) A review of the literature was conducted for structural and curricular development of a group visit. Results: 30% (4/12) of those invited to the focus group attended. All who attended were eager to participate in group visits. The resulting projected number of Dr. Holland's patients who would be interested in group visits is between 21-32 patients, a sufficient number to make the endeavor worthwhile from a business standpoint. Interdisciplinary support (RD) is available. Conclusions: Group visits are a feasible option in John Day, in terms of interest and from a business perspective. A packet of information for the clinic was compiled that should facilitate this endeavor.

A standardized admission order for COPD exacerbations at Blue Mountain Hospital in John Day, OR
Date of project: 4/25/2005

COPD is an extremely common chief complaint in the aging population and an exacerbation of COPD is one of the most common presenting complaints at the Blue Mountain Hospital emergency room in John Day, OR. Physician admission orders can be as diverse as the physicians themselves and may also represent a significant point of confusion for nursing and respiratory therapy staff. This project was designed to produce a COPD exacerbation standardized admission order that incorporates individual physician preferences, proven efficacious therapies, local formulary and logistical restrictions, but also an easy-to-read document to which hospital staff can refer for high-quality patient care.

Hyperlipidemia in Grant County: Is the Public aware of the dangers of elevated cholesterol levels?
Date of project: 4/25/2005

The cardiovascular risks associated with hyperlipidemia have been well established through multiple studies. The public’s understanding of this issue, however, has lagged behind scientific discovery, and failure to make appropriate life style changes may unnecessarily lead to an early demise. A recent article published by the Center for Disease Control and Prevention (CDC) showed that too few Americans have their serum cholesterol checked as recommended by the National Cholesterol Education Program (NCEP). My objectives in this project were to first identify the prevalence of hyperlipidemia in Grant County, Oregon and then conduct an informative discussion with the public regarding cholesterol physiology. Using a computer generated list, I was able to identity 282 adults who receive care at the Strawberry Mountain Wilderness Clinic in John Day, Oregon who carry the diagnosis of hyperlipidemia. Based on this number, the calculated prevalence of hyperlipidemia within this cohort was 6.7%, far short of the national average of 24%. Following this discovery, I held a 45-minute PowerPoint discussion in an attempt to enhance the public awareness of the dangers associated with hyperlipidemia and presented potential solutions to this problem. My interactions with the group lead me to the conclusion that the public’s knowledge regarding cholesterol health is insufficient, though a more thorough investigation is needed to substantiate this hypothesis. Furthermore, I believe that with more physician-directed discussions, the public will take a more active role in screening and reduction of hyperlipidemia.

Use of Alternative/Herbal Medicines Among Family Practice Patients in Rural Eastern Oregon
Date of project: 3/21/2005

The popularity of complementary and alternative medicine (CAM) among the general public is irrefutable.1 It is also increasing.2 Importantly, the greatest relative increase in CAM use between 1997 and 2002 was seen for herbal medicine.3 In parallel with this rise there is increasing evidence citing reactions and side effects of alternative/herbal medicine use as well as possible interactions with conventional medicine.4,5 A study in 2002 looked at CAM use among primary care patients in a rural setting in northern Pennsylvania.6 However, there is no previous study that has looked at its use, and specifically alternative/herbal medicine use, in rural eastern Oregon. This study has two (2) aims: 1) to determine the frequency and types of alternative/herbal medicines being used by patients in Grant County, Oregon; and 2) to determine the rate of physician notification of alternative/herbal medicine use and reasons for not disclosing its use. Methods: A questionnaire was distributed to 235 adult patients in two family practice clinics in John Day, Oregon. Results: Response rate was 99.6% (235/236). Fifty-five percent (55%) of patients reported using at least one form of alternative/herbal medicines in the past 12 months. The most common alternative/herbal medicines used were green tea (16%), megavitamin (13.9%), glucosamine (11.5%), Echinacea (11.5%), fish oil (6.9%), soy products (6.6%), and ginseng (3.9%). The number one reason to use alternative/herbal medicine was for health maintenance (22.6%). The majority (52%) of patients self-prescribe alternative/herbal medicines. Only 46.5% of patients told their physician about their use of alternative/herbal medicine. Conclusion: A significant number of rural family practice patients are using alternative/herbal medicines. A public educational campaign, with inclusion of the need to report such usage to the family physician, should be implemented, and questions on the use of alternative/herbal medicines should (continue to) be incorporated as an integral part of the history taking by primary care physicians.

Prevention of Traumatic Pediatric Falls in Grant County Oregon
Date of project: 3/21/2005

Trauma is the number one cause of mortality and morbidity in children ages 0- 14 years old. This study compares national and Grant County trends in fatal and nonfatal trauma focusing on unintentional fall injury in a rural community in eastern OR. Although MVA represent the number one cause of mortality among pediatric populations, accidental falls and fall related injury provide the number one source of morbidity and hospitalization among children aged 0-14. We sought to examine the trends of pediatric fall related injury in a rural community in order to focus efforts at prevention of morbidity amongst this vulnerable population. Systematic review of all emergency room visits among patients aged 0-14 between 1/1/1999-12/31/2004 at Blue Mountain Hospital in John Day Oregon were evaluated. Injury trends were determined by examining data included presenting complaint, primary diagnosis (ICD-9), and injury mechanism (E-code). Results: Mechanism of injury leading to ER visits in peds 0-14YO: FALLS 310 (31%), BLUNT TRAUMA 123 (12%), SHARP OBJ 101 (10%), MVA 78 (7.8%), REC VEH (3%), BIKES 62 (6.2%) HORSE REL INJ (1.7%) SPORTS 55 (5.5%) Mechanism of falls: GROUND LEVEL/NOS 102 (35%), PLAYGROUND EQUIP 31 (10%), FURNITURE/BED 30 (9.7%), ON OTHER OBJ/NOS 28 (9.1%) SPORTS 12 (3.9%) STAIRS 12 (3.5%) Types of injuries secondary to falls:OPEN WOUND OF HEAD, NECK, AND TRUNK 76 (22.7%), CONTUSION WITH INTACT SKIN SURFACE 71 (21.2%) FX OF UPPER LIMB 61 (18.2%), SPRAINS/STRAINS OF JOINTS 58 (17.3%) Falls represent a significant source of traumatic injury in the rural pediatric population of John Day, OR and surrounding communities. Prevention measures are a major public health concern and prevention efforts in Grant County should be focused at prevention of accidental falls at home (furniture/bed falls) and school (playground equip). A brochure on child safety and prevention was developed with the concerns of this rural community to be distributed at the emergency room to parents of children aged 0-14 years old.

Gambling in John Day, Oregon: Creation of a Patient Brochure.
Date of project: 2/7/2005

Gambling is a prevalent problem both nationally and in Oregon. It can have wide-ranging effects, including those on finances (like bankruptcy), higher rates of receipt of past-year unemployment and welfare benefits, arrest, incarceration, divorce, poor or fair physical health, and mental health treatment. Despite this prevalence, it is not routinely screened for in a family practice clinic in John Day, Oregon, and there is no current patient information brochure here addressing it. The purpose of this project was to develop a patient information brochure to address gambling in one rural Oregon family practice clinic. The patients of this clinic were the target population. Data was gathered by speaking to the clinic’s provider as well as a gambling counselor regarding the negative effects of gambling and things to include in a brochure. An extensive Internet search was also undertaken to gather information. This data gathering yielded the creation of a brochure that included the following information regarding gambling: basic statistics, forms and locations in which it takes place, negative effects, common myths, screening questions, and treatment resources. If there were more time in the clerkship it would have been beneficial to try and observe whether the brochure prompted any discussion between patient and provider, as well as to try and contact other providers in the area to see if they would like to display the brochure in their offices.

Working toward a Community based education approach for Diabetes management and prevention of complications in John Day, Oregon
Date of project: 2/7/2005

Diabetes is a disease that is approaching epidemic proportions in the US. It is a disease with high morbidity and mortality due in large part to its complications. Intensive therapy has been shown to be important in the prevention and control of diabetes. Community - based education is one modality of treatment that has been shown to work to prevent development of, and reduce complications of diabetes. In this study I surveyed 68 diabetes treatment and management where patients had questions. The results of this survey show a high interest in small group-based education for diabetes. Issues that many diabetics had questions about included nutrition, medications, need for specialist exams, and blood testing. These topics could be covered in group-based education and supplemented with a brochure/handout. The results of this survey and production of this handout may be useful building blocks to establish community-based or small-group education in John Day, Oregon.

The birthing experience in Grant County, Oregon
Date of project: 1/3/2005

John Day, like many other rural communities in Oregon, was recently faced with a dilemma: to continue obstetrical care by physicians despite rising malpractice insurance costs or as a community decide to no longer provide these services. While this debate directly influences the physicians and their patients, other allied health care workers in Grant County will also be affected. There are currently two options for obstetrical care in Grant County: the family practice clinic of Drs. Holland and Nichols or the local direct entry midwife, Sherry Lauer-Dress. The physicians provide standard medical care including routine lood work, ultrasounds and deliver at Blue Mountain Hospital. Sherry provides the same care by law, including access to order laboratories and ultrasounds at BMH, homeopathic medicine, and only does home deliveries. The question 1 addressed was threefold: 1. What percentage of women in Grant County are receiving first trimester prenatal care? 2. What form are they choosing- the traditional medical MD model or the alternative nurse-midwife model? 3. What does the lay midwife model entail? The methods include obtaining the breakdown of all birth certificates issued in 2004 from Grant County Health Department, conduction a chart-review of all the Blue Mountain Hospital deliveries, and interviewing Sherry Lauer-Dress and several postpartum patients. The results showed that Grant County issued fifty-seven birth certificates in 2004. Forty-eight of those were delivered at Blue Mountain Hospital (BMH), five were delivered by Sherry and four were delivered in hospitals in other counties. Ninety-five percent of BMH delivered patients had documented 1st or 2nd trimester prenatal care. The midwife patients had an average of 100% 1st trimester care. A summary of the interviews with Sherry and the postpartum patietns are presented in the results section.

The Idiosyncrasies of Rural Mental Health: Taking a closer look at women's perceptions of available mental health services, as well as their own psychosocial risk factors, Grant County, OR.
Date of project: 10/18/2004

Mental health disorders are a major public health concern in the United States. Although access to services can be limited in rural areas, this study attempted to explore both perceived barriers to mental health care, as well as personal psychological and social risk factors that may affect emotional well-being. A survey was devised to address three categories: (1) the impact of psychosocial risk factors, (2) perceptions of local mental health services, and (3) the role of the rural doctor in treating mental illness. Because of their statistically increased risk of experiencing depression and anxiety, women eighteen and older were identified to complete this survey. Results showed that although women in Grant County tend to have a low severity and frequency of identified risk factors, they have a considerably low self-esteem. This is particularly evident amongst the surveyed elderly population. While this may not directly contribute to mental illness, it can increase vulnerability to those already at risk. Women appear to be accessing mental health services as needed, and generally perceive their family physician to be an additional good resource. This emphasizes the central role that primary care doctors play in rural mental health.

A Survey of Alcohol Use Amongst Seniors at Grant Union High School In John Day, Oregon
Date of project: 10/18/2004

Underage drinking continues to be a problem among adolescents and has serious social, health, and economic consequences. The purpose of this study was to identify the prevalence of alcohol use among 12th grade students at Grant Union High School (John Day, OR) compared to that of high school students throughout the United States. It is hoped that the information gathered will be used by school district authorities to assess the success of currently instituted alcohol prevention programs, stimulate thought into further methods of prevention, and help promote student understanding and insight into the pitfalls of alcohol abuse. The study was conducted in a survey format, which was completed by individual students on a confidential and anonymous basis. The final results of this project show that alcohol use is common among students at Grant Union High School, with many of them being initially exposed to alcohol at an alarmingly young age.

Tobacco Use Cessation in Grant County: An Evaluation of Available Resources and Development of a Patient Handout
Date of project: 9/13/2004

Quitting smoking or chewing is a difficult process regardless of whether it is attempted in an urban or rural environment; however, major differences exist in community attitudes and the support resources available that impact success. This project examines how practitioners in John Day, Oregon manage patients, the resources available to offer those who are interested in quitting, and the community values that influence cessation efforts. Interviews were conducted with five family medicine health practitioners in John Day and the Alcohol and Tobacco Prevention Specialist for the Grant County Center for Human Development. In addition, a training session for managing smoking cessation in pregnant women sponsored by the Grant County Public Health Department was attended. These sessions revealed medical practitioners as the primary source for cessation information and support with no local secondary resources available for referral and a community where tobacco use, especially chew, is seen as a norm. In an effort to aid cessation counseling at both the practitioner and public health level, a handout was created to address issues faced by smokers at various stages of the quitting process. The handout can be used to supplement cessation counseling in a clinical setting where time is limited yet is also broad-based enough to help those seeking to quit outside of a practice setting.

Poisoning Cases in Grant County, OR
Date of project: 8/9/2004

Poisonings represent a major public health problem, however, specific causes may be community-specific. Often poisoning cases presenting to an ER are managed by boarded emergency medicine physicians, trained in managing toxicology cases; however, in a small community like John Day, OR, the ER is staffed entirely by primary care physicians. This study examined all poisoning cases presenting to the Blue Mountain Hospital’s Emergency Department in 2000-2003, with the intent of characterizing this community’s toxicology patterns and medical management. The goal was to determine which educational resources could be provided to the community (patients and/or physicians) to most effectively reduce poisonings or improve management of poisoning cases. Sixty cases meeting the study’s criteria were reviewed, and it was determined the hospital’s physicians do not currently need further education about toxicology resources or management of a poisoning patient. However, teenagers and parents of toddlers have the greatest potential for effective education regarding poisonings, and recommendations for future projects to address these needs are discussed.

Colonoscopy awareness and compliance among patients of Strawberry Wilderness Family Clinic in John Day, OR.
Date of project: 7/5/2004

Colon cancer screening can be a challenging issue in rural regions. The following study addressed several issues of colorectal screening such as availability, public awareness and compliance with colonoscopy at the Strawberry Wilderness Family Clinic in John Day, Oregon. A questionnaire was designed in order to evaluate compliance with colonoscopy among patients ages 50 and above. Compliance is defined for this study as the percent of patients who followed their doctor’s recommendation to have the colonoscopy procedure. All of the responses to the questionnaires were compiled and analyzed. Moreover, research was done in order to investigate the availability of colonoscopy for the patients in John Day. The overall compliance with the procedure was 76%, however 18% of the patients questioned were unaware of procedure in general. It was determined that the John Day community has a high rate of colonoscopy compliance. This was attributed to the fact that this screening procedure is readily available for patients in this rural community.

Exploring Teenage Pregnancy Prevention in John Day, OR: Development of teen education material for birth control method selection
Date of project: 7/5/2004

The purpose of this project is to investigate the teenage pregnancy rate and services available to adolescent women in John Day, Oregon. For the past few years, family physicians in John Day have noticed a trend in younger teens becoming pregnant in their small town. They have also reported that adolescent women in their rural community are often more likely to choose to keep their pregnancy and raise their children when compared to their urban counterparts. Teen pregnancies and adolescent childbearing is a important issue for rural towns due to the strain it causes on their limited financial and medical resources as well as the social and health consequences to these parents and their children. Since most programs to prevent pregnancy or adolescent motherhood have targeted young women who reside in metropolitan areas, it is important to evaluate whether similar resources should be directed at rural communities. This project intends to achieve two goals: first, examine the trend in the number of teenage pregnancies in rural counties in Eastern Oregon in comparison to urban counties along the I-5 corridor as well as assess whether or not current programs for teen pregnancy prevention are adequately thwarting the number of adolescent girls becoming pregnant in John Day, OR. Second, as part of the effort of teen pregnancy prevention, a patient education handout was created in order to better assist teens in selecting a birth control method.

Facing the loss of obstetrical care in Grant County: Is the community prepared?
Date of project: 5/10/2004

Multiple studies have shown that many rural Oregon clinicians performing obstetrical deliveries have already stopped or plan to stop providing this service in the near future. Despite malpractice subsidization efforts such as the Rural Medical Liability Financial Reinsurance, these rates continue to soar, forcing many physicians out of obstetrical practice. The number of physicians who routinely perform obstetrical care in Grant County has dwindled in recent years, such that only one family physician performing OB remains in this isolated county of 8,000 people and 5,000 square miles. If no viable alterative is identified, he, too, will likely stop providing OB care in one month and women will be left to drive long distances for prenatal care and their delivery. In the advent of this potential crisis, this project was designed to assess the community’s preparedness for this transition, as well as childbearing women’s intentions for obtaining prenatal care. These goals were obtained through two methods: 1) a 12-question survey of 33 pregnant and postpartum women that sought information on demographics, risk factors, barriers to receiving care elsewhere, and anticipated plans at the onset of labor, and 2) interviews with community health partners to identify problems, concerns, and potential solutions that might prevent or minimize the impact of the crisis. Survey results revealed a population of many Medicaid patients and first-time mothers. Although most women reported a willingness to travel for prenatal care, 82% stated they would go to the local hospital in Grant County at the onset of early labor signs, suggesting the need for continued emergency OB services. Results of the interviews with health leaders are summarized in a problem/solution format. The results were shared with the same community health partners to assist in their preparedness planning.

Assessing Needs, Access, and Barriers to Alcoholism Treatment in the Rural Community of Grant County, Oregon
Date of project: 5/10/2004

Alcoholism and its negative social, economic, and medical consequences increasingly pose major problems in the American society and important challenges in doctor offices, especially in rural settings where there are few available resources. It is the objective of this study to attempt to assess the needs for, the access to, and the barriers against alcoholism treatment in Grant County, Oregon. The design of the study includes multiple facets of researching work on available literature and published reports, reviewing medical records in medical facilities, meeting with personnel involved in alcoholism treatment programs, and attending Alcoholics Anonymous meeting, all of which focus on the population of Grant County, Oregon. Published data regarding the rate of alcohol misuse and abuse in Grant County which would be reveal a lower rate of alcoholism in Grant County as compared to that of the entire state of Oregon (6.7% vs. 7.8%). However, the needs for alcoholism treatment in Grant County are still considered greater that those of the rest of Oregon with finding of greater magnitude of negative consequences of alcoholism in Grant County, i.e., alcohol-induced death, alcohol-related traffic fatalities, adult alcohol-related arrests, and drunken driving arrests. It was so found that 207 people in Grant County sought treatments in four of major resources for alcoholism help in Grant County (Blue Mountain Hospital, Strawberry Wilderness Family Clinic, Grant County Center for Human Development, and Alcoholics Anonymous program) in the period of about one year through medical records. The rate of utilization of medical help of 207 makes up only 43.5% of the 476 in needs for alcoholism treatment, suggesting multiple barriers that are difficult to identify. Among these barriers are finance with Grant County being one of the poorest county in Oregon with high unemployment rate (16.9%) and low educational level (15.5% without high school diplomas), low affordability of alcoholism treatments (high rate of uninsured population of 16.47%), social stigma, and other factors unique to each alcoholism treatment options in Grant County.

Obesity and clinical interventions in John Day, Oregon: Develpment of a patient handout.
Date of project: 3/29/2004

Obesity is a growing problem in the US and in Oregon leading to several chronic health problems. This study evaluates clinical interventions and community resources for patients wanting to loose weight in John Day, Oregon. A family physician was observed providing recommendations on diet and physical activity changes intended to result in weight loss. Due to time constraints in a busy practice, several times the conversation had to be limited. The clinic routinely weighed patients but calculation of a patient's body mass index was rarely calculated. The office lacked printed material to raise awareness of how weight affects health or health or diet and exercise suggestions for weight loss to offer patients. A survey of community resources was completed including interviews with a county health nurse and nutritionist. There were limited community resources and no information about them in the clinic. Two patient handouts were developed and made available to patients. The handouts were used as an aide to provide information and tools for patients to refer to at home.

Colorectal Cancer, Screening for Prevention: How well is Rural Oregon Doing?
Date of project: 3/29/2004

BACKGROUND: Colorectal cancer is the third leading cause of cancer related death in Oregon, and it ranks fourth in incidence with five new diagnoses of invasive colorectal cancer occurring daily. The US Preventive Services Task Force recommends universal screening of men and women age 50 years or older for colorectal cancer. This study sought to evaluate how well physicians in John Day, Oregon were providing screening for their patient population. METHODS: Chart review to determine screening practices was completed with 100 randomly selected charts of current patient age 50 and older. Interviews with physicians in the community were held to identify barriers to screening, and hospital medical records were reviewed to determine if colonoscopy-screening rates had improved since the time when a surgeon performed the procedure rather than family physicians. RESULTS: Of the 100 charts reviewed, 36% of patients had been screened, 26 by colonoscopy, 5 by flexible sigmoidoscopy, and 5 with fecal occult blood testing. Three percent additionally had screening studies either recommended recently or were scheduled for the near future. The number of colonoscopies completed at Blue Mountain Hospital has increased considerably since family physicians have been trained to perform the procedure. There was an average of 13 colonoscopies performed over 3 years while a surgeon alone was performing the procedure compared to 36 completed in 2003 by three family physicians. CONCLUSION: While the number of people being screened for colorectal cancer each year in John Day is increasing, the majority of patients over the age of 50 years have not been screened for colorectal cancer. Barriers identified include inadequate insurance coverage for preventive procedures, lack of time for physicians to discuss the necessity of screening, and patient disinterest for the topic of colon cancer.

Patient medication knowledge in Grant County, Oregon
Date of project: 1/5/2004

Most older Americans take 3-5 medications daily, but many patients have inadequate knowledge of the medications that they are taking. In a New York study, less than 15% of elderly patients were able to accurately identify the names, doses, dosing schedule and indication for all of their medications. 80 consecutive adult patients at the Strawberry Wilderness Family Clinic in Grant County, Oregon were asked complete a medication list at their medical appointment, indicating name, dose, dosing schedule, prescriber and indication of any medication they took regularly, including prescription, over the counter and herbal remedies. The adults taking regular medications took an average of 5.3 daily medications and knew the names and indications of an average of 69% and 59% of these, respectively. In an effort to educate patients, a one page handout on the importance of taking an active role with their medications and a wallet-sized medication log were distributed with the medication survey.

The Frequency and Pattern of Dermatological Cases in a Rural Primary Care Practice in John Day, Oregon
Date of project: 1/5/2004

Studies have demonstrated that up to one third of patient visits to general practice physicians are for skin problems. However, there is not much information on the frequency of dermatological diseases in rural areas in the United States. Objective: To evaluate the frequency and the pattern of dermatological diseases in a primary-care-practice population in John Day, Oregon in order to decipher the epidemiological medical conditions and to better address them. Results and conclusion: 27.7% of the diagnosis in a John Day primary care practice were of dermatological origin. Surprisingly, Actinic Keratosis was the highest dermatological diagnosis, accounting for 20%. This figure is high compared to other studies mainly due to the high outdoor activities and occupations in rural areas such as John Day. This demonstrates the importance of rural physicians having further training in diagnosing and managing pre-malignant skin changes and other conditions of high frequency in their medical population. This also enforces the use of teledermatology to better manage difficult dermatology conditions without having to send many patients out of town for consultations. Intervention: In order to educate the patient population about high rates of pre-malignant skin lesions, a pamphlet regarding skin cancers was designed and distributed to patients with high risk factors.

Medical Management of Heart Failure in John Day, Oregon: Implementation New Practice Guidelines.
Date of project: 11/10/2003

Heart failure is a major health concern in the United States. Nationally, over twnty perxent of hospital admissions are for heart failure. More than two-thirds of patients diagnosed with heart failure are treated by primary care physicians. This is certainly the xase in John Day, Oregon, where there are few spexialists present on a regular basis. As the population ages and life-ecpectancy of other cardiac diseases increases, heart failure will become even more of a public health concern. In the past several years, many studies have been published and new guidelines have been put forth for the management of heart failure. Optimal medical management of heart failure and improvement patient education can reduce thenumber of hospitalizations. This study aimed to determine if new treatment recommendations were being put into practice by local family practitioners in John Day. A pre-printed admission order form for heart failure and a discharge checklist with patient education materials were developed to help implement the current treatment guidelines.

Breastfeeding in John Day and Grant County: Development of a Patient Handout to Encourage Breastfeeding
Date of project: 9/29/2003

The advantages of breastfeeding are well documented in scientific literature, and it is apparent that it is in the best interests of public health to encourage breastfeeding. The purpose of this project was to identify the resources available to residents of John Day and Grant County with regard to breastfeeding support, and to encourage breastfeeding through the use of a handout in the clinic. National and local statistics on breastfeeding were noted, as well as possible reasons that women quit breastfeeding. Benefits of breastfeeding were researched and summarized, and online and local resources were included in the flyer as well in an attempt to improve breastfeeding participation. The small numbers of women giving birth in Grant County made it unrealistic to determine the impact of the handout during the rotation, but the handout was well received by clinic physicians and staff.

Breast Cancer Screening of Postmenopausal Women
Date of project: 9/29/2003

With the growing percentage of elderly Americans, osteoporosis and its consequent health risks are becoming an increasing public health concern. Routine screening guidelines have been proposed by many health organizations to evaluate the bone density of those at greatest ri9sk of osteoporosis, especially postmenopausal patients receive screening at a rural family medical outpatient clinic in John Day, Oregon. A chart review was performed and found that only 21% of postmenopausal women age 65 and over had been screened while 50% of postmenopausal women between ages 50 and 65 had been screened. Patients who had been screened were more likely to have come in for routine physical exams at which time appropriate screening test were recommended. Of those patients who had not been screened, many visited the clinic onlyfor treatment of acute medical conditionsof for follow up of a focused chronic medical condition. Recommendations for improved screening rates include increasing patient awareness of osteoporosis prevalence and morbidity as well as taking advantage of focused patient visits to recommend bone density screening.

A study of Drug, Alcohol and Tobacco Use Among 7th Graders in Grant County
Date of project: 11/10/2003

Drug, alcohol and tobacco use by adolescents are not only prevalent in urban cities but in rural areas as well. Several studies have shown the importance of parental communication on adolescent behavior, especially those who are in their early teens. A reduced rate of alcohol, tobacco and illegal drug use by teens is correlated with positive relationships with and clearly communicated expectations by parents. This study attempted to identify the rate of alcohol, tobacco and illegal drug use by 7th grade students in three rural middle schools in Grant County and compare that to the average in communication as well as to identify if parents were communicating clear expectations regarding alcohol, drug and tobacco use. Information obtained will be used by both school administrators and local physicans to determinine the need for screening, education and intervention in this age group. Furthermore, as the school district implements a similar survey for 8th grade students, they will use the information obtained to follow students throughout their middle school years and for grang writing purposes. Lastly, results obtained will be used to educate parents in Grant County about the importance of discussing alcohol, tobacco and drug use in this age group and the effect that communicationg clear expecations can have on their child's behavior.

Mental Health Services in Grant County: Challenges & Progress
Date of project: 8/18/2003

With budget cuts limiting the availability of services for mental health, small rural communities like Grant County are the hardest hit. The central goal of this project is to provide an initial framework of the nature of mental health services that exist in Grant County. The design for this project includes internet searches via the DHS website and an interview with the director of mental health services at the Center for Human Development. Grant County Center for Human Development is located in John Day, OR. It is the only place in the county that specifically provides mental health services. Yet, Grant County has a population of approximately 8000 people. As a result there is limited access to mental health services. However, other significant challenges include a limited staff, of which an overwhelming percentage is not appropriately trained to properly handle assessment and treatment planning. Furthermore, the study reveals that there is poor patient management and a laid-back approach to intervention. The encouraging aspect of the study is that the staff is receiving more training, a crisis worker has just recently been hired, and an improved method of documentation is being devised to better manage patients and the course of their treatment outcomes. Future plans call for the establishment of a psychiatric emergency unit in Grant County and contributions from residents and medical students in terms of sharing their time and knowledge with the mental health department staff in an effort to improve the quality of mental health services in Grant County.

Care Of The Type 2 Diabetic in John Day, OR
Date of project: 7/7/2003

Type 2 diabetes mellitus (DM) continues to progress to epidemic status in America today. It is an illness that requires both diligent and coordinated care of a gifted team of medical professionals. In a rural community the responsibility of care coordination, as well as other roles usually filled by consultants, lies in the hands of the primary care physician. A two physician, private practice clinic in John Day, Oregon, was the site of a quality assessment project that both examined and attempted to improve the consistency and quality of diabetic care. A system modeled after the pap and physical reminder cards was implemented with a trial of fifteen patients.

Childhood Immunization in John Day, Oregon: Development of A Patient Education Handout for Use In the Clinical Setting
Date of project: 7/7/2003

The development and application of widespread vaccination to prevent disease is considered to be one of the most notable public health achievements in history. The immunization campaign in the United States has succeeded in reducing the incidence of devastating childhood illnesses dramatically, nearly eradicating many diseases from the population at large, but immunization rates are dropping both nationally and within the State of Oregon. In Grant County in 2001, only 73.6% of children between age two and three had received all the recommended vaccines. Among other reasons, many children are not being vaccinated because of parental fear, ignorance, and misguidance due to anti-vaccine information presented on the Internet and by the mass media. The Strawberry Wilderness Family Clinic in John Day, Oregon lacked vaccine information available to parents in a condensed format that addressed the importance of timely childhood vaccinations in general. A concise, one-page handout was created to address the concerns of parents regarding childhood immunization and was implemented for use in the clinical setting.

Child abuse/neglect trens, domestic violence/sexual abuse victims and resources available in Grant County
Date of project: 8/18/2003

Child abuse and domestic violence are prevalent in all 36 Oregon Counties. This study addressed the higher incidence of child abuse in Grant County and the lack of resources available to help domestic violence victims in this community. Using several sources of information the study found that Oregon child abuse reports have increased 10.9% in 2002 over one year period., whereas the number of victims increased 2.3%. Over the past three years Grant County has had greater victim rate/1000 as compared to Oregon. In 2002 Oregon's child abuse victim rate/1000 was 9.7, a decline from the 2000's 12.2/1000. In the other hand Grant County ranked eighth out of 36 counties in Oregon in number of victims/1000 in 2002 with 17.7, a slight increase from the 2000's 16/1000. Grant County ranked as the worst County in percent of children that re-enter foster care within 12 month of leaving foster care, and ranked second as worst stability of child foster care placement during the April-June 2002 period.

Identifying senior services available in John Day, OR and making those services known to seniors and families caring for the aging in John Day and Grant Co.
Date of project: 5/5/2003

The nations population of people over age 65 has grown and will continue to grow in the coming years. Many people in this age group need assistance with health and daily activities and communities are having to find ways of providing assistance and educating the public about those assistance programs. This community project attempted to identify the senior services available in John Day, OR and make those services known to seniors and families caring for the aging in John Day and Grant Co. The design was observation of medical staff’s identification of senior patient’s needs and the referral system for those patients and families to senior services. Patient and staff knowledge and utilization of senior services was also observed. There are many resources and contacts available for seniors in John Day and Grant County, but no concise compilation of information for those needing senior services now or in the future and a noted under utilization of some services. There is a mechanism in place for identifying people in need of senior services, but it is mainly used only for hospitalized patients and it was felt that the rest of the medical community and general population would benefit from knowledge of the senior services available in the community. The only handout readily available was geared more for hospital and nursing home staff to use or give to those patients and families in those settings. Furthermore, the handout was more of a listing of phone numbers and details betters utilized by the medical community than the general population. Therefore, the final product of this project was development of a concise handout to be, given to patients and families in the clinics, hospital emergency room, and newcomers and the general population via the chamber of commerce.

The Screening and Control of Hypertension Among Diabetics by Family Practitioners in Rural John Day, Oregon.
Date of project: 3/24/2003

Hypertension in diabetic patients leads to multiple and severe complications. In 2002, the American Diabetes Association recommended that blood pressure in diabetics be maintained below 130/80 with an optimal goal of 120/80. But studies indicate that only 11-25% of diabetics with hypertension are effectively managed to meet the ADA standards. Via a chart review of 83 diabetics, this study provides an assessment of screening for and control of hypertension among diabetics in rural John Day, Oregon. Four primary aspects of care were evaluated including the prevalence of hypertension among the patients, the adequacy of screening, the adequacy of starting treatment, and the efficacy of the treatment. Additionally, a comparison between the two clinic physicians was executed in an attempt to identify any variations in practice measures. Results indicate that 21.6% of definitively hypertensive diabetics in John Day, Oregon are effectively screened and managed. However, this success rate drops to 18.6% if patients with borderline hypertension are included in the study pool. Both of these values suggest that the efficacy of hypertension screening and management in rural Oregon proves comparable to the national standard. Interestingly, the comparison of physician practice profiles reveals differing tolerances with respect to meeting ADA recommendations suggesting individual variation. It appears that these discrepancies stem from differences in training depending on when the physician was trained and what the management criteria for hypertension in diabetics were at that time. To educate physicians about current guidelines and to facilitate the ease of patient monitoring, a Diabetic Flow Sheet was created to be included in the charts of diabetics. The hope is that this will improve the screening and management of hypertension in John Day to a level that far exceeds the national average.

Nutrition and Fitness: Development of a Program to Supplement Physician Intervention in Management of the Health Risks of Obesity.
Date of project: 12/30/2002

Obesity and its many associated health risks is a growing problem in the United States. This study attempted to identify strategies for physicians to increase their effectiveness in promoting dietary modification and weight loss for overweight patients at a family practice clinic in John Day, Oregon. The design was observation of physician interaction with overweight patients motivated to lose weight, and one on one dietary counseling with self selected patients. Community resources available for patients include a dietitian who visits the community monthly, and a new fitness center. Additionally patient handout availability and effectiveness was examined. While the physicians were actively discussing the importance of diet and fitness with their patients, time limitations prevented adequate follow up. Many patients expressed bewilderment at the amount of different diet information available via the popular press. Patients requested basic, simple guidelines to help them start meeting their weight loss goals. Handouts currently available at the clinic are from the American Heart Association, and while quite comprehensive were described as “confusing” and “overwhelming.” The final phase of this project thus involved the creation of a short, simple handout that outlined suggested dietary modifications for weight loss.

Community-acquired pneumonia
Date of project: 9/23/2002

Community-acquired pneumonia (CAP) is a common reason for admission to the hospital. All patients admitted to the Blue Mountain Hospital in John Day, OR with a diagnosis of pneumonia for a one year period (September 1, 2001 to August 31, 2002) were identified and their charts reviewed. In addition to basic demographic data, diagnostic studies and antibiotic therapy used were identified. These data were compared to the current existing recommendations for diagnosis and treatment of CAP. The results of this comparison were then distributed to all of the physicians in John Day to help them to continue to make informed decisions regarding the diagnosis and treatment of CAP.

Conversations and Perspectives on Attention Deficit Disorders in Grant County, Oregon.
Date of project: 8/12/2002

The goal of this community project was to examine the perceptions, detection and diagnosis, and tratment and managment of attention deficit disorders, with (ADHD) or without hyperactivity (ADD), in a small rural community such as John Day, Oregon, and within the surrounding country. Conversations with three professionals intimately involved with the diagnosis and/or management of AD(H)D and a member of a family dealing with ADHD were held and recorded on mircocassette, and the contents were then transcribed. From these conversations, it appears that the unique blue-collar, small-town environment of John Day serves to discourage the rampant use of medication in the treatment of AD(H)D, despite universal agreement among the four interviewees concerning its effectiveness. However, nearly all endorse an increasing prevalence of acceptance of attention deficit disorders as legitimate and treatable illness amongst the local populace. Although resources are limited in such a sparsely populated region, community networks involving local physicians, the Mental Health Service, and the local school districts offer ample aid for those dealing with AD(H)D. While gaps still exist in terms of coverage and communication among the players and with those affected by AD(H)D, it appears that there is adequate coordination and comprehensiveness to successfully manage the great majority of young persons suffering from disorders of attention.

Emergency Need Occupational Injuries in a Rural Town Setting: John Day, Oregon
Date of project: 7/1/2002

Work place injuries continue to be a major concern in many blue-collar industries across the United States. In rural Northeastern Oregon these blue-collar industries are the predominant basis of the economy and thus on-the-job injuries are of major importance. This study was designed to evaluate which industries have the most on-the-job injuries that require emergency room treatment in and around the town of John Day, OR. The design was observation of Blue Mountain Hospital Emergency Department visits during a six-week clinical rotation with a local physician, as well as an extensive medical records compilation for the past year of all emergency room visits classified as on-the-job injuries. In this study, it was found that many injuries occurred as a result of inexperience in high turnover positions and seasonal, long work hour positions that led to intense physical activity without proper equipment and training. Of those injuries that were preventable in nature, lack of equipment such as proper gloves and boots as well as lack of training in operation of heavy equipment led to most injuries. Therefore, the most important conclusion of this project was that although these industries carry much inherent danger, better training and equipment could significantly reduce the number of work related injuries in John Day.

Who Will Catch the Babies? The Impending Medical Liability Crisis in Grant County, Oregon
Date of project: 3/25/2002

With the rising cost of medical liability insurance premiums, it is becoming unaffordable to practice obstetrics in Grant County, Oregon. One of Grant County's five physicians has already decided to quit practicing obstetrics and if premiums increase much more, it is likely that the remaining four will follow the same path. The result will be additional problems with access to care in rural communities. Expecting mothers in Grant County will have to drive over two hours for obstetrics care. In this paper I will look at how other states in the country are dealing with this problem and what the OMA and AMA are recommending for further action. With this informaiton, I will assess what the physicians and residents of Grant County can do to initiate change to avoid a medical liability crisis in Oregon.

Medical Triage Guidelines for an Assisted Living Facility in John Day Oregon
Date of project: 2/11/2002

Inappropriate use of the ambulance and emergency room by the staff and residents of Valley View assisted living residence was identified as source of frustration among the physicians of John Day. The cause of this problem is the very limited medical training of the med aid staff at Valley View. An algorithm consisting of a series of simple yes/no questions was proposed as a triage system that would match the medical training of the staff at Valley View to the expectations of the local physicians. The triage algorithm was presented to the staff at Valley View and is being implemented on a trial basis. Once the Valley View staff have become comfortable with the tool and it has been in use for several months the local physicians will be polled to evaluate the triage system's effectiveness.

Mortality Trends In Grant County, Oregon: 1995-1999
Date of project: 1/2/2002

This project sought to study the leading causes of mortality in Grant County, and to determine if they differ from the rest of the state. The study design was a retrospective analysis of mortality data from 1995-1999. Overall mortality rates, deaths from major cardiovascular disease, malignant neoplasms, chronic respiratory diseases, diabetes, accidents and suicides in Grant County were compared to the state rates. It was found that major cardiovascular disease, malignancy, and chronic respiratory disease were the leading ceases of death in Grant County. Additionally, the overall mortality rate, death rate from malignancy (specifically colon cancer), and death rate from chronic respiratory diseases were found to be significantly (P<.05) higher than the state rate during the period studied. The causes of these increased rates are uncertain, but further investigation is recommended to determine if changes in community education and/or preventative medicine would help decrease these mortality rates.

Firearms and Parental Perceptions on Gun Safety in Grant County.
Date of project: 5/6/2002

This study sought to examine parental perceptions on firearm safety among Grant county residents. A 6-item questionnaire was distributed to all patients visiting the Strawberry Wilderness Family Clinic from May 20 to June 10, and customers at two local supermarkets on the weekends of June 1-2 and 8-9. Outcome measures are prevalence of firearms in households, practice of safe storage, history of firearm safety discussion with children, and parent's opinion on hypothetical situations involving a child and firearms. Among the 148 participants in the survey, 82% reported having at least one piece of firearm in their household. Of these, 60% stored loaded firearms in the house without a secured or locked cabinet. Among parents owning one or more guns, 75% have discussed firearms safety with their children, 38% thought their less than 6 year-old child can distinguish a real gun from a toy gun.

Effects Of The Oregon Health Plan In John Day, Oregon.
Date of project: 9/24/2001

Since the Oregon Health Plan was implemented in 1990, there has been a statewide decrease in per capita health care costs, a greater than 50% reduction in uninsured children, and a nearly 50% reduction for adults. (1) OHP has clearly made a positive impact on the shape of health care in Oregon. I became curious about the impact of OHP on rural clinics and communities while rotating at Strawberry Wilderness Family Clinic in John Day, Oregon. Does accepting OHP patients put rural physicians and clinics at a financial disadvantage? Has OHP accomplished its goal of ensuring adequate health coverage to the people in rural communities? SWFC has three family physicians and one PA who, along with two other family doctors, provide the entire population of Grant County with primary care. These five physicians see outpatients, manage inpatients, and cover the Emergency department. They are extraordinarily dedicated and possess diverse skills. The sources of my information were varied, including discussions with professionals in various realms of the health care industry, statistics and reports published by the Oregon Health Policy and Research office and AHEC, financial data provided by the clinic administrator, and legislative reports. What follows is a synopsis of the information I gathered. This information leads me to believe that even under a fully capitated managed care environment, the clinic is quite successful and the community is well served by the Oregon Health Plan.

Bioterrorism Response Plan For Grant County.
Date of project: 9/ 24/2001

Since September 11th, 2001, the number one thing that seems to be on everyone's mind is terrorism. Based on the definition of terrorism, acts committed with the purpose of terrorizing a population, the terrorist who committed the atrocities in New York and Washington were successful. Since the attacks, America has been scrambling to develop ways to prevent and respond to future terrorist activities. Of highest interest is toxic terrorism, which is the use of nuclear, biological or chemical warfare to create terror. By their very nature, nuclear and chemical warfare results in illness minutes to hours after the attack in persons close to the location of weapon release. Because of this, the first responders would be firefighters, police and emergency rescue workers, who would cordon off the area, decontaminate patients, and administer antidotes. However, in the case of biological terrorism, the effects of the biological attack may not be known for days to weeks and in persons widely dispersed from the site of release. Affected persons would present with an undiagnosed illness to clinics or emergency departments. Physicians would then have to recognize that the patient is affected by an unusual illness and treat with vaccines and antibiotics, making primary care physicians the method of surveillance for an unknown biological terrorist attack. While attending the American Academy of Family Physician Annual Congress in October of this year (2001), I noticed that the physicians in attendance were keenly aware that they would need to be vigilant in monitoring for signs of a biological attack, and that they were unprepared. It was noted in a recent Family Practice News that American physicians are not trained to recognize the signs and symptoms of agents that are likely to be used in an attack. What training that is available is geared to police officers and firefighters. The other concern is that once a physician has identified a patient, who is possibly affected by a terrorist agent, what do they do next. With this in mind, I returned to John Day with the idea that I would develop a bioterrorist response plan for Grant County.

Smoking Cessation In Grant County
Date of project: 8/13/2001

Smoking continues to be one of the most significant issues in healthcare. Nicotine use and dependence has been clearly and repeatedly identified as a risk factor in a myriad of diseases and is specifically known to have an adverse affect on the morbidity and mortality associated with heart disease, hypertension, diabetes, COPD and many other ailments. However, tobacco use continues in our society even in light of its well-known risks. Certainly, smoking cessation is a key point for nearly every healthcare provider in the clinical setting. Numerous studies have described the powerful role that physicians play in smoking cessation. Many people identify their doctor's encouragement and advice as a major factor in their decision to quit and also in their ability to achieve long-term success(1). Other studies have shown the effectiveness of physician counseling combined with the physician-directed use of cessation aids, most commonly nicotine replacement (in the form of patches, gum and nasal sprays) or Zyban/bupropion (2). Even in light of this data, there are reports that physicians are still missing opportunities to counsel their patients about the risks of tobacco use and provide information about products and programs which can potentially reduce symptoms of physical and psychological withdrawal and increase a patient's chance for long-term success. For example, a recent study in the Journal of Family Practice announced that less than 50% of patients surveyed reported receiving cessation advice from their physicians (3). For my community service project, I studied smoking cessation trends in Grant County, namely: the percentage of people who identified themselves as smokers; the percentage of people who had smoked in the past and quit successfully; the number of smoking cessation attempts (successful or unsuccessful) in each group; what aids, if any, were used during these cessation attempts; if the patient had ever been advised by their physician to quit, and,; if this advice was a factor in their decision to quit.

Measure 12-35: A Community In Conflict
Date of project: 7/2/2001

Change is never easy. Some face it with optimistic curiosity; others cling to the old with a titanic grasp. To regard things new with some apprehension is human nature. We are constantly comforted by the familiar, and often resist the unknown. In the United States, however, and especially here in Oregon, we pride ourselves in our ability to initiate and adapt to changes in our society. Oregon was the first state in the union to adopt legislation to protect its natural habitat (State Sanitary Authority, 1938). It was also the first to expand Medicaid healthcare coverage for its poorest citizens (Oregon Health Plan, 1989), and the first to give its terminally ill the right to die (Death with Dignity Act, 1994). Yet sometimes our ability to resist change can with such intensity rival our ability to accept it. With every move there is a counter, with every decision, controversy. In September of 2000 a special election was held in Grant County, Oregon to provide funding for the remodeling and renovation of Blue Mountain Hospital in John Day, Measure 12-35, which authorized general obligation bonds of up to $7,000,000 for hospital construction, narrowly passed carrying only 50.9% of the popular vote. From the moment of its inception to well after the measure had passed, the issue was entrenched in controversy. Those offering support were committed to providing adequate healthcare services to the surrounding community, while those opposed stressed social and economic concerns. Both sides were adamant in their beliefs, and the ensuing conflict proved turbulent for the small communities of eastern Oregon.

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