RCHC Community Project Abstracts

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Chronic Pain Management Protocol: for utilization by primary care providers in Lebanon, OR
Date of project: 10/12/2009

Chronic pain is a growing problem in healthcare today. It is unlike many other medical problems that primary care physicians are presented with throughout their clinic day. Chronic pain has many different components and is sometimes referred to as a “biopsychosocial” problem potentially including aspects like trauma, anatomical abnormalities, psychosocial influences and many others. Interdisciplinary approaches to managing pain have been proven to be effective at reducing pain and at decreasing narcotic dependence. Involving multiple modes of support addresses the complexity of people’s pain, and gives many different ways to make lifestyle modifications to help patients better understand how to manage their pain. In order to address the issue of a family medicine provider as a manager of chronic pain, I decided to help the Lebanon, OR family practice with implementing a protocol for evaluation of chronic pain. My goals included increasing access of protocol forms by facilitating incorporation of them into the electronic medical record. I also put together a patient handout that included simple ideas for an interdisciplinary approach to chronic pain management as well as more specific local resources.

Diabetic foot ulcers
Date of project: 8/3/2009

The idea behind this project was to create a informative patient friendly handout with regard to diabetic foot ulcers. Diabetic foot ulcers are a common potential long term complication of diabetes. In the Mid Valley Medical Plaza about 2% of diabetic patients have this particular diagnosis. However currently there isn't a easy to understand, accessible resource to teach patients about diabetic ulcers. The goal of my project was to create a handout that would fulfill these requirements. A handout was created that was composed of 3 sections: what diabetic foot ulcers are and how they form, how to prevent ulcers and how to manage ulcers.

Health Provider Emergency Preparedness to Swine Flu in Lebanon
Date of project: 4/27/2009

This project is a report on how health providers in Lebanon prepared and responded to the H1N1 influenza outbreak. The resources available to the health providers were the recommendation and guidelines from the CDC, the Oregon Department of Health, the Linn County Health Department and the Samaritan Health Services. Health providers encouraged patients to follow the CDC recommendations on practicing good hygiene habits. They stayed informed by following the daily updates of the Oregon Department of Health and Linn County Health department websites. Health providers implemented the triage guidelines from the Samaritan Health Service officials to prevent over utilization of the clinic. As a result of these strategies health providers in Lebanon were able to efficiently respond to the small surge in medical demand and at the same time continue providing their usual medical care.

Stress Induced Illness; diagnosis and treatment in Lebanon, Oregon
Date of project: 3/16/2009

The primary goals of this project were to better understand the diagnostic approach to stress-induced illness and effective treatment modalities. These questions arose from patient interactions surrounding stress-induced illnesses which left both the patient and provider feeling frustrated and confused. I recognized my own inability to effectively diagnose and treat stress-induced illnesses and wanted to know more. On further examination, I found 27% of patient visits to the PCP office in Lebanon, OR, over a 5 week period, were related to stress-induced illnesses. These included chronic back, neck, and body pains without clear etiology, depression, anxiety, irritable bowel syndrome, and generalized fatigue. Patients often re-presented with repetitive pain complaints after steroid injections, medications, or “tincture of time” did not adequately treat their illness. Methods: I interviewed specific inpatients and outpatients, selected based on their diagnosis of exclusion, stress-induced illness. I investigated the pathophysiology of stress-induced illnesses, diagnostic algorithms, and treatment modalities through literature review. Finally, I followed up with as many patients as I personally saw in clinic, to better understand the efficacy of different treatments. Results: Stress-induced illnesses are prevalent in the primary care setting, making up 27% of Physician-visits in Lebanon, OR over a five week period. Effective treatment is time consuming up front, but inexpensive. When appropriate treatment is implemented, it has the potential to save over five hundred dollars and ten physician hours per week, not to mention, considerable human suffering.

Vaccination Hesitancy in Lebanon, OR
Date of project: 2/9/2009

Increasingly more Oregonian parents are hesitant to adhere to physician-recommended vaccination schedules for their children. This student attempted to a) accurately describe the rate of vaccine hesitance and b) define reasons behind this hesitancy in Lebanon, OR. Rates of non-vaccination in Lebanon were computed by data from the Linn County Public Health Office. Patient opinions regarding vaccines were collected from 30 patient interviews. The interviews were formatted on a questionnaire created by the investigator. In addition, conversations were conducted with pediatricians and DHS officials regarding this subject. Based on the data from Linn County Public Health, Lebanon has a lower rate of vaccine refusal than the state average. Parental concerns regarding vaccines appear to reflect those expressed in a large-scale statewide study, chiefly among them 1) the belief that children are generally vaccinated at too young an age and 2) concern for a link between vaccines and autism.

Implementation of Personal Health Records in a Rural Community
Date of project: 12/29/2008

The term "patient-centered care" is an often-used catch phrase in family medicine. This approach includes core values such as information sharing, participation and collaboration. Stemming from these ideas, interest in the development of personal health records (PHR's) has been a recent hot topic in the world of Health Information Technology. PHR's are a patient-directed tool that may help to deliver integrated, portable, interoperable, patient-centered care. They have many projected benefits especially in rural communities. These benefits include reaching out to areas of unmet need, helping to protect isolated communities, empowering patients and enlarging the "virtual" healthcare network. However, significant risks and barriers to implementation exist and these must be further defined, analyzed and accounted for before PHR's can become a reality. As such, with this project I sought to develop a thorough understanding of OHR's and analyze the risks, benefits and barriers to implementation in a rural community. Overall, PHR's have many potential benefits but implementation will require overcoming many barriers (financial, logistical, and technical) and carry significant security risks to all parties involved.

Development of Two Innovative Programs in Lebanon, Oregon: Build Lebanon Trails and Planting Seeds of Change
Date of project: 9/8/2008

Obesity, and the myriad negative health consequences that accompany it, continues to rise throughout the US, Oregon, and especially eastern Linn County where greater than 66% of the population is overweight or obese. Medical costs for obesity-related health problems in Oregon's adults totaled an estimated $781 million in 2003 - a number that will rise much higher as the current population ages. While some changes have already been implemented to combat unhealthy weight, further work is needed. The Community Health Improvement Partnership (CHIP) program has aided in the development of two innovative programs in Lebanon, OR - Build Lebanon Trails (BLT) and Planting Seeds of Change (PSOC)- that approach this end from different angles. In meeting with the CHIP coordinator and leaders of BLT and PSOC, I found that both programs were recently created and have many obstacles to surmount before they can reach their full potential. During my time in Lebanon I worked with both to help them overcome some of these barriers and aid the programs in progressing to their final goals.

Planting Seeds of Change: Improving the Health of the Community - an Edible Endeavor
Date of project: 8/4/2008

Childhood obesity is an enormous issue facing the health care system, schools, and the community at large. This study examined a community initiative, Planting Seeds of Change, whose mission is to increase healthy eating habits and reduce childhood obesity through a garden based educational endeavor. The project entails the formation of a school based garden which grows produce used in the school lunches and serves as a classroom without walls for the children of Seven Oaks Middle School. This study hoped to gather the pertinent information about the formation, maintenance, and future aims of the project so as to consolidate this information into a working summary to be shared with others. The study also examined the statistics of childhood obesity and literature which detailed community and/or school based efforts to combat obesity. Research was conducted via interviews, observation, and literature searches. The final result was a detailed PowerPoint presentation discussing Planting Seeds of Change and the literature supporting such a community based initiative, which will be utilized at several state and nationwide meetings and conferences.

Exploring the Potential of Art Therapy as Complementary Medicine in the Treatment of Chronic Pain
Date of project: 6/30/2008

Chronic pain is a complex health problem and a source of frustration for both doctors and patients. In treating only the physical component of chronic pain, allopathic medicine fails to adequately address the psychosocial, emotional and spiritual components. The purpose of this project was to explore the potential of one modality, art therapy, as complementary medicine in the treatment of chronic pain. While art therapy has been applied in the psychiatric and oncology settings for many years, little research has been conducted on the potential benefits of art therapy as complementary medicine in the treatment of chronic pain. My project included extensive on-line research of websites devoted to art therapy, search of journal articles in Medline, search and identification of art therapy resources in the Lebanon area, sharing my own experiences using art as therapy, and reading The Art Therapy Sourcebook. I proposed further avenues for research on the efficacy of art therapy in treating chronic pain and explained why this could be a valuable form of complementary medicine in a rural setting. Finally, I sought to leave a tangible source of inspiration for patients at the clinic by designing and completing a large painting. Chronic pain is a complex health problem and a source of frustration for both doctors and patients. In treating only the physical component of chronic pain, allopathic medicine fails to adequately address the psychosocial, emotional and spiritual components. The purpose of this project was to explore the potential of one modality, art therapy, as complementary medicine in the treatment of chronic pain. While art therapy has been applied in the psychiatric and oncology settings for many years, little research has been conducted on the potential benefits of art therapy as complementary medicine in the treatment of chronic pain. My project included extensive on-line research of websites devoted to art therapy, search of journal articles in Medline, search and identification of art therapy resources in the Lebanon area, sharing my own experiences using art as therapy, and reading The Art Therapy Sourcebook. I proposed further avenues for research on the efficacy of art therapy in treating chronic pain and explained why this could be a valuable form of complementary medicine in a rural setting. Finally, I sought to leave a tangible source of inspiration for patients at the clinic by designing and completing a large painting.

Provision and Utilization of IUD’s in Linn County, OR
Date of project: 4/28/2008

IUD’s are the most effective and least expensive long-term contraceptive. Outside the US, they are the most common form of birth control used by married women. IUD use in the US was curtailed due to concerns regarding safety after a number of cases of PID and TSS in the 1970’s. Since then, IUD’s have been redesigned to eliminate this safety issue and have an exemplary safety profile. Despite this, IUD’s continue to be underutilized leading to a significant number of unintended pregnancies and unnecessary patient suffering. This study attempted to determine the utilizations and provision of IUDs in Linn County, OR. This was accomplished by phone interview with the practice manager for all Family and Ob/Gyn practices in Linn County and utilized annual billing for IUD procedures from these practices. The results of this study indicate that in Linn County 1.2% of women between the ages of 15-49 use IUDs (vs 2% US and 13-14% worldwide) and that only 32% of qualified providers are actually providing IUDs. Based on the results of this study, Samaritan Health (which manages 90% of Family and Ob/Gyn practices in Linn County) agreed to organize an IUD CME course to encourage Linn County providers to increase IUD use.

Primary Care in the Digital Age: Developing the next step of quality care delivery using computer resources in Lebanon, Oregon
Date of project: 3/17/2008

Rural primary care in the United States faces a set of challenges in the upcoming years, chief among these is the lack of enough primary care providers to support a growing population, as it ages and manifests complications of chronic illnesses related to obesity. Rural areas face the added difficulty of recruiting new doctors, with a net effect of leaving fewer PCPs to care for more patients in rural areas relative to urban areas. This project explores patient and physician perspectives on using the electronic health record and on-line resources to expand and streamline the care given to the Lebanon community within the Samaritan Health System. Using a 10 question online survey administered to patients over a two-week span and discussions with IT, administration, and physicians, I attempted to quantify patient desire and ability to engage more actively in their health maintenance. I also identified several possible future steps towards streamlining the delivery of care and engaged providers to learn the barriers and opportunities to test and integrate such measures. The overall conclusions drawn from these brief surveys were 1) the community may not yet be ready for or interested in deep online participation in their care; 2) several barrier exist both at the technical (software) and administrative levels to quick and agile trials of possible streamlining measures, and 3) despite these two facts, the opportunity exists at little to no initial cost to begin implementing future electronic functions that may likely ease the transition to future clinical advances.

What Are The Barriers To Childhood Vaccinations In Lebanon, Oregon, And What Can We Do About Them?
Date of project: 12/31/2007

Undervaccination of children is a nation-wide problem. Every year, children die from vaccine-preventable diseases as the nation fails to increase the average up-to-date (UTD) at 24 months vaccination rate above 71%. Many resources are being developed to overcome barriers to increased vaccination rates, including computerized immunization programs that collect vaccination records on children in a geographical area rather than in a particular clinic. Mid Valley Medical Plaza (MVMP) in Lebanon, Oregon, is fortunate to live in a state with an established computerized immunization record, Oregon Immunization Alert (OIA). At MVMP, however, this valuable resource was not being fully utilized. The purpose of this project was to examine the current vaccination delivery system at MVMP and design a simple, efficient, and effective protocol to implement the use of OIA into the care of the family physicians’ pediatric patient population. The hope was that this would lead to increased vaccination rates. The study began with a quantitative study to determine the UTD rate of a small sample of the patient population, which revealed similar vaccination rates between MVMP and the nation. Interviews with healthcare workers revealed similar barriers in the clinic in Lebanon, Oregon as are faced in clinics across the nation. An extensive literature search on the barriers and solutions to vaccination delivery supported the integration of OIA to help improve vaccination rates in the pediatric patient population of MVMP. The protocol was then designed. In order to effectively convey the need for change, and therefore the worth of creating and implement a solution, a formal proposal to implement the simple protocol was developed.

“The asthma burden in Lebanon, OR: development of a patient handout for education of newly-diagnosed and current patients with asthma”
Date of project: 9/10/2007

With a population of 13,940, Lebanon, Oregon comprises 13% of the total population of Linn County and is the second largest incorporated town in the area. Given the vast amount of dedicated land to farming, agriculture is the largest industry in the county. It should be no surprise then, that Linn County has a large frequency of respiratory ailments. Compared to the other 35 counties in Oregon, Linn County has the highest prevalence of asthma (11.9%), more than a one-quarter more than Multnomah County (8.9%). With an increased prevalence of asthma in the county, it is essential that patients have readily accessible resources for education on this respiratory condition. This study attempted to identify those available resources and then develop a concise and comprehensive handout for a Lebanon family practice clinic. The design was observation of family physician’s interactions with newly-diagnosed and active patients throughout the course of a six week rotation in a high prevalence setting. A cursory investigation of available handouts yielded a lack of material on respiratory ailments. Therefore, the final product of this project was the development of a basic educational patient handout for those who have been recently diagnosed with asthma and those who desire more information on asthma. The goal was that this handout would work by improving knowledge about a common disease, foster discussions between patients and physicians, and provide patients with additional resources for further education.

Methamphetamine Use and Treatment Resources in Lebanon, OR and Linn County
Date of project: 7/2/2007

I contacted DHS, Linn County Alcohol & Drug, and Dr. Carol Chervenak (OMA Methamphetamine (MA) Task Force/ABC House Medical Director) to inquire about MA use/abuse in Lebanon, OR and the surrounding communities. Through working with Dr. Chervenak, and educating myself in regards to MA use/abuse, I became aware of the magnitude of the MA problem in the area, and furthermore, the MA treatment problem was brought to my attention. In turn, I decided to investigate community resources available for those seeking help for themselves/family members addicted to MA. In the past, I had only heard vague references as to how difficult it was to get adequate inpatient treatment for MA use. I wanted to create a list of local resources that patients could access when confronting their addiction or the addiction of a loved one. Upon investigating this issue, I found more community resources than I anticipated. I found a variety of treatment options that were committed to treating drug users from all walks of life. I contacted DHS, Linn County Alcohol & Drug, and Dr. Carol Chervenak (OMA Methamphetamine (MA) Task Force/ABC House Medical Director) to inquire about MA use/abuse in Lebanon, OR and the surrounding communities. Through working with Dr. Chervenak, and educating myself in regards to MA use/abuse, I became aware of the magnitude of the MA problem in the area, and furthermore, the MA treatment problem was brought to my attention. In turn, I decided to investigate community resources available for those seeking help for themselves/family members addicted to MA. In the past, I had only heard vague references as to how difficult it was to get adequate inpatient treatment for MA use. I wanted to create a list of local resources that patients could access when confronting their addiction or the addiction of a loved one. Upon investigating this issue, I found more community resources than I anticipated. I found a variety of treatment options that were committed to treating drug users from all walks of life.

Shoulder injuries and rehabilitation
Date of project: 3/19/2007

Shoulder injuries are one of the most common musculoskeletal injuries in Lebanon, Oregon. The only injury more common is low back pain. While working there, it became apparent that there was need for educational material to share with the people of Lebanon. Although in the office we could show pictures and describe how to care for their shoulder injury, we had no hard copy of information to reinforce the patient’s newly acquired knowledge. Additionally, there is a large amount of the population that was receiving all of their rehabilitation care through the physician’s office. These patients did not have access to therapy services, or they were unable to go secondary to lack of transportation, or work, or funds. For the patient who supports themselves by ranching, farming, or working in a factory, a shoulder injury, like a rotator cuff, can be a devastating and debilitating injury. Besides affecting their occupation, this also affects patient’s self care, leisure activities, and even rest. Even if they did have access to Physical Therapy, there was often a great deal of patient education that needed to occur while in the physician’s office, as well as a need for a written material for the patient to refer to when at home.

Acceptance and Use of the HPV Vaccine in Lebanon, OR: Creation of an educational patient handout to increase awareness, acceptance, and use of HPV vaccines.
Date of project: 1/1/2007

A vaccine against HPV and Cervical Cancer was recently FDA approved for use in the United States, representing a major public health advancement and effective method for decreasing the prevalence of an aggressive malignancy. This study attempted to assess the educational resources available for patients about the HPV vaccine as well as the use of the vaccine in a rural family practice clinic in Lebanon, Oregon. The design was to observe current methods of patient education for the HPV vaccine and the number of times the vaccination was given over a five week rotation. Informal interviews with physicians in the clinic, as well as patients, were conducted to access common questions and concerns about the new vaccine. The process of obtaining the vaccine as well as the rate of administration was assessed with the physician interviews, as well as talking with clinic staff. Due to the relatively short duration of vaccine availability and lack of informative yet concise materials, patients were uniformly unaware of the accurate details about the HPV vaccine and no vaccines had been given. Since the vaccine had a designated target population, those eligible were easy to identify and the barrier to patient education was seen to be the lack of an educational handout. Not only does the possible recipient need information, but the captive audience includes young females starting at age 9, which often includes parents in the educational equation. Therefore, the final product of this project was a concise yet appropriately informative patient handout to explain HPV; it’s relation to Cervical Cancer, and the HPV vaccine to adolescent females 9-15 years old and their parents to increase accurate awareness and subsequently utilization of the vaccine.

"Music Therapy: what it is, what it does, and how it is used in Lebanon, OR"
Date of project: 9/11/2006

“Music Therapy” is a term that has been used to define many different forms of alternative medicine practices, the most popular and studied of these being the use of live music by a Certified Music Practitioner (CMP) to ease pain, stress, depression, and anxiety. By the very nature of their health status, many patients who are chronically ill or near-to-death undergo significant stress and anxiety. This reduces their quality of life at a time when quality of life is essentially the only area left to make improvements in. While traditional medications are frequently used to make patients more comfortable, many patients and families desire a more “natural” or “spiritual” option. Music therapy can satisfy that desire. While the statistical evidence for music therapy’s efficacy is limited (like most alternative medical disciplines), the anecdotal and subjective responses to the sessions are very positive. In surveying the use of music therapy in the Lebanon/Albany/ Sweet Home area, I found that while all hospice patients in the area are offered music therapy sessions, less than 25% take advantage of the option. Of those that do, the therapy is met with an overwhelmingly positive response, with noticeable (though subjective) improvement in over half of the patients.

Mental Health Resources in Linn County, OR for the Uninsured
Date of project: 7/3/2006

Prevalence of uninsured patients in Oregon is on the rise. Among these patients are those with mental health needs. This project aims to assess the need for mental health care in Linn County and to research the available mental health resources for the indigent uninsured that are unable to pay for their care. Research was conducted through interviews with possible mental health providers. The organizations offering mental health care to the indigent were identified to include: Linn County Mental Health Clinics, Community Outreach Clinics together with Samaritan Health Care providers, Pastoral Counseling Center, and The Counseling Center of Albany. The ultimate goal was to develop a brochure to be made available for patients with mental disorders coming in to the Community Outreach Clinics in Albany and Lebanon, Oregon.

School Based Health Center in Sweet Home, Oregon: Current self-reported health related issues and current acute-care facility usage.
Date of project: 3/20/2006

There is an ongoing project by the Linn County Department of Health Services to start a school based health clinic in Sweet Home, Oregon. In an attempt to aid in the planning for this project, this report summarizes the Oregon Healthy Teens survey results for Sweet Home, and looks at emergency department and urgent care facility usage by high school aged children from this city. Findings include similar prevalence of self-reported alcohol use between Sweet Home and the state average (45.2% vs. 47.4%), as well as similar rates of use of other substances. Sweet Home students are more likely than the state average to report having had sexual intercourse, but are also more likely to report having used a condom and/or birth control. Self-reported asthma has a significantly higher prevalence in Sweet Home than across the state (16% vs. 10.8%), and is more likely to have caused students to miss school. The prevalence of self-reported depression is similar between Sweet Home and the state average (7.3% vs. 6.3%), but Sweet Home students are more likely to have considered suicide within the past year (18.1% vs. 12%). Also, at least 281 (39%) of ED/UC facility visits by this population were likely to have been issues that could have been handled appropriately in a primary care setting.

Mental Health Care Resources in Linn County
Date of project: 1/2/2006

Mental healthcare delivery everywhere is being provided to greater extents by primary care physicians than ever before, especially in rural settings where community mental health resources are lacking. This report assesses the prevalence and disease burden of mental illness in the U.S. overall, and in our rural communities like Linn County. Second, it discusses barriers to mental health care in rural settings. Next, it poses possible solutions to rural disparities in mental health care. Finally I discuss my project. The goal of this project was to examine the need for mental health services in Linn County, identify mental health resources in Linn County, and formulate a consolidated list of local mental health resources including their areas of expertise for use by local health care providers and community members.

Patient Education Materials at the East Linn Community Clinic: Providing a Much Needed Resource.
Date of project: 9/12/2005

The East Linn Community Clinic provides free medical care to uninsured citizens of Albany and Lebanon, Oregon and their surrounding communities. The clinic has struggled to obtain and provide educational handouts for the patients who utilize their services and they desired to improve this aspect of their care. Interviews with two individuals closely connected to the clinic were conducted to better understand their need and educational materials were loaded onto a laptop computer donated to the clinic. Materials were downloaded from well-known medical sites on the internet and a letter of request for a donation was sent to a prominent patient education software company. In addition, readability levels of patient handouts were compared.

Low Vision in Lebanon: Resources to maximize quality of life with permanent vision loss
Date of project: 7/4/2005

Visual impairment and blindness affects 2.94% of Oregonians and in the near future is expected to affect even more of the progressively aging population. A significant number of those affected have vision loss that is not correctable by surgery, medications, or glasses, placing them in the category of low vision. Vision loss and blindness can be psychological and physically devastating and requires unique coping skills and support. It is important to properly educate patients with vision loss about the resources available to them and emphasize that their quality of life can be better maintained by utilizing these resources. This project sought out the resources available to low-vision individuals in Lebanon, OR. Meetings with a low-vision specialist, a patient with low-vision who attends support groups in Lebanon, and representatives from Oregon Commission for the Blind and Vision Northwest made possible the investigation of resources. Low-vision evaluations by a specialist provide evaluation of daily functionality, optimize use of vision aids such as magnifiers and other tools, allow patients to experiment with tools before buying, and provide a specialized refraction for low-vision individuals. Oregon Commission for the Blind provides home evaluations by specialists for safety, independence, and use of low-vision tools. Additionally, they provide vocational rehabilitation and training, counseling for patients and families, scholarships, assistance with mobility tools such as white canes, and donation service for low-income individuals. Vision Northwest is a non-profit provider of low-vision assistive devices and also has a donation service for people with limited income. A monthly support group meets in Lebanon and allows its members to share tips on living with low-vision, emotional coping mechanisms, and has presentations with particular relevance to low-vision by members of the community. An informational handout was developed to summarize low-vision resources in Lebanon for patients and providers.

Urgent Care Center in Lebanon – another example of serving the needs of the community
Date of project: 2/7/2005

Developing a healthcare systems centered around the needs of a community has been an evolving and ever developing process spanning the past two decades in the small community of Lebanon, Oregon. Earliest efforts consolidated a group of primary care physicians – Family Practice physicians and Internists – employed under the umbrella of Samaritan Health Services. These efforts were directed toward providing primary health care focused on community need. By placing primary care office visits under the larger Samaritan Health Systems organizational umbrella, primary care physicians could better spread the responsibility of caring for all in the community -- those with insurance, those without insurance, as well as recipients of Medicare, Medicaid, and Oregon Health Plan. In 2000 when outside independent Urgent Care organizations were seriously looking at Lebanon as a new location of a “doc in a box” center, Samaritan Health Services rallied again in their “community needs” approach. From these efforts were born the remodeling efforts of the Samaritan Lebanon Emergency Room, designed to provide adjoining Urgent Care / Emergency Room services at the local Lebanon hospital. Since its opening in 2001, the Samaritan Lebanon Urgent Care has been well received by the community as well as area PCP’s, and has become a successful and profitable addition to the Samaritan Network of HealthCare Services. Providing adjunct services to those provided by a patient’s PCP, acute health care issues can be handled in the same day, without an appointment, at a cost equal to or within 5% of a standard PCP office visit. Minor acute illness and injuries can be funneled to the urgent care center for treatment. There, patient care does not incur the high costs of Emergency Room handling, and ER volume strain is reduced. The Samaritan Lebanon Urgent Care center is open 7 days a week, handles between 50 to 75 patient cases daily, and provides acute healthcare to patients with private insurance, Oregon Health Plan, Medicare, Medicaid, as well as self paying patients.

The Role of a Free Clinic in a Small, Rural Town: A case study in Lebanon, Oregon
Date of project: 10/18/2004

Free clinics are located all over the United States, in urban and rural areas alike. These clinics strive to serve the needs of people without health insurance, without access to care, and often, with significant medical illness. These "band-aid" measures to care for the growing access problem in this country serve a vital role in the current health care picture. Communities struggle with increasing numbers of poor and uninsured people with decreasing funds to serve their communities. In Lebanon, Oregon there is a free clinic funded by a hospital foundation that attempts to serve the needs of those without access to health care in East Linn County. While working at the free clinic I discovered a very important lesson: free care is a symbol greater than that of individual health care, it is one of community health.

Japanese Healing Gardens
Date of project: 8/9/2004

The negative effects of stress and anxiety have been well documented in past research and effect psychological, physiological, and behavioral health. Many find hospitals to be complex, confusing, and anxiety-inducing environments, imparting a sterile, institutional vibe to patients and staff. This observation has led architects, psychiatrists, neuroscientists, and health care workers to collaborate on a movement behind “evidence based design.” They promote their research findings that show that environment does effect health, and changes in hospital design can be followed by improved patient outcomes and increased staff satisfaction. As stress and anxiety levels fall, patients and staff feel and do better. A leading investigator in the field, Roger Ulrich, found that positive distractions, such as nature, are especially helpful. He found that patients recovering from surgery with a window view of nature have shorter recovery times, request decreased dose and strength of pain medication, and have fewer post-op complications. Incorporating nature into hospital design has also been shown to improve staff satisfaction and staff turnover, attract more patients, and increase charitable donations. Lebanon Community Hospital is currently in the midst of construction of a Japanese Healing Garden. Many patients and staff are uncertain as to the purpose and usefulness of such an undertaking at a time when resources are in short supply. Thus, I decided to focus my community –oriented primary care project on investigating the topic of healing gardens, including the evidence behind constructing healing gardens in healthcare settings and measurable patient outcomes. Japanese gardens are specifically addressed, and the symbolism involved, in order to more fully explain the components of the LCH garden. Lastly, a few suggestions are made to avoid problems encountered by other facilities, as well as an effort to generate ideas for a research project to monitor the effect of the healing garden on patient and staff.

Childhood Obesity: How Does Lebanon Compare to the Nation?
Date of project: 5/10/2004

Background: Obesity is becoming a major public health problem that needs to be addressed in the clinical setting. The National Health and Nutrition Examination Studies (NHANES) have monitored the prevalence of overweight children in the United States for the past three decades. The most recent NHANES study shows about 15% of children ages 6-19 are overweight. Problem: The prevalence of overweight children in the Lebanon, Oregon community is unknown. Non-systematic observation would suggest the prevalence of overweight children to be greater than the national statistic. To determine the prevalence of overweight children in the Mid-Valley Family Practice Group (Lebanon, Oregon), a cross-sectional study was conducted. Methods: The sample population was derived from children who presented to the Mid-Valley Family Practice Group (Lebanon, Oregon) for well child exams during 1999 and 2000. A total of 77 charts were reviewed for height, weight, and age. Children with a body mass index (BMI) of ³ 95th percentile for age and gender were identified as being overweight. Results: In the study population, 20% of children ages 6-11, and 35% of children ages 12-19 were overweight. Conclusion: Childhood obesity is a real health problem both nationally and in the Lebanon community. Clinicians should be aware of this growing number of overweight children, monitor BMI on a yearly basis, emphasize prevention in non-overweight children, and recognize when intervention for weight loss is indicated.

Treatment of Opiate Addiction in Rural Communities
Date of project: 3/29/2004

Background: Opiate abuse is a chronic, relapsing brain disease with significant public health implications. Traditionally, methadone maintenance is the standard of care for this disorder. Methadone maintenance is structured so that, at least initially, patients must present to the clinic every day to receive their dose. The nearest methadone clinic to Lebanon, Oregon is over 30 miles away, which poses a significant barrier to care to those seeking treatment. In addition, physicians in Lebanon recently decided not to implement a methadone maintenance program due to concerns about financial constraints and community perception. The purpose of this study was to determine whether office-based treatment of opiate addiction with a sublingual formulation of buprenorphine and naloxone is a viable alternative to the treatment of opiate addiction for rural communities with limited access to a methadone maintenance program. Methods: A literature review was conducted to determine efficacy of buprenorphine/naloxone in the treatment of opiate addiction. A Medline search of English language articles pertaining to human subjects provided four studies. Results: The studies showed that buprenorphine alone is as efficacious as equivalently dosed methadone. One study showed that, in comparison to placebo, a sublingual formulation of buprenorphine and naloxone is safe and reduces opiate-addicted patients’ cravings when used in a primary care setting. Conclusion: Buprenorphine is a safe and efficacious alternative to methadone for rural communities with limited access to a methadone maintenance program. However, the cost of the medication and restrictions placed on providers limit the potential for this medication.

Teenage Pregnancy in Lebanon, OR: physician attitudes and development of an educational handout for new parents
Date of project: 1/5/2004

Teenage pregnancy, although on the decline, continues to be a major health issue in the United States. This study attempted to evaluate attitudes toward teenage pregnancy and produce an intercention aimed at helping these young parents once they have made a decision to parent the child. The design was a survcey administered to health practitioners in a family medicine setting, and chart review of pregnant women in the clinic practice. Observational evaluation of local services available to pregnant women was performed. Throufh interaction with teen parents in the clinic wellchild checks, firsthand information was obtained about lack of knowledge of local resources available. After a web search of pre-existing resources, meeting with a prenatal class instructor, and feedback from practitioners, a handout of essential parenting and safety information was compiled, including a list of phone numbers for important resources for parents. The handout was disseminated into the clinic practice to be given out at the two- week well-child check, and also incorporated into the prenatal class curriculum.

Early intervention to prevent diabetes in Lebanon, Oregon: development of a patient education pamphlet on insulin resistance syndrome for clinical use
Date of project: 11/10/2003

Insulin resistance syndrome (IRS) has been established as the predictor for diabetes1. The prevalence of insulin resistance in the U.S. is estimated at 70-80 million. Without intervention or treatment, patients with this disease will progress to impaired glucose tolerance or overt diabetes within 10 years2. Primary care physicians are currently actively identifying patients whom they suspect to have insulin resistance or at risk for pre-diabetes so that aggressive lifestyle modification can be used to prevent the progression from insulin resistance to overt diabetes in these patients. In Lebanon, Oregon, family physicians are diagnosing many patients with insulin resistance syndrome or pre-diabetes. As a result of the complexity of this disease, patients often fail to understand their disease and its implication on their health or the goal of the treatment; therefore, they often become noncompliant with treatment plans (diet, exercise and hypoglycemic agent such as Metformin). Patients diagnosed with this syndrome are asymptomatic and are less motivated to change their lifestyle than patients with other diseases such as myocardial infarction. Newly diagnosed patients are initially educated with slides on the topic of insulin resistance at their doctor's office in the Mid-Valley Medical Group. These educational slides are provided by the Endocrine Society as a patient education aid3, 4. However, patients remain unsure and confused about their diagnoses of IRS and require subsequent reinforcement during follow-up visits, pre-diabetic classes and discussion with registered dietitians. During the first week of my rural rotation, I had to explain to many patients at the Mid-Valley Medical Group practice what insulin resistance is by using diagrams and hand drawings. I quickly realized the need for a patient educational pamphlet on insulin resistance syndrome. This patient pamphlet would also serve as a resource for pre-diabetic patients and introduce them to the pre-diabetes classes offered by Samaritan Lebanon Community Hospital (SLCH). This pamphlet was put into clinical use during the last week of my rotation in Lebanon and was very well accepted by patients and physicians.

RSI for the Lebanon Fire District
Date of project: 9/29/2003

The purpose of this study is to determine whether the Lebanon Fire District (LFD) has the need for a Rapid Sequence Intubation (RSI) program. The American College of Emergency Physicians recommended that RSI be practiced by all emergency physicians and is also currently practice by Paramedics in 29 states that allow such procedures. We developed an objective set of criteria for RSI candidates and then applied this in a retrospective records review to define the number of candidates in the patient population. We found that of 3 of the 14 intubations preformed this year meet the criteria for RSI. All of these patients were managed by other means of airways control. Due to the low number of candidates, lack of poor outcomes, and limited resources available to maintain a RSI program we feel it is not justified in the case of the LFD.

Diabetes Management Guidelines in Lebanon.
Date of project: 8/18/2003

My rural rotation took place in Lebanon, Oregon. During my five weeks there, I encountered several patients with poorly controlled diabetes. Therefore, the goal of my community project was to increase the awareness and the knowledge level of patients with diabetes. I created an informational sheet that physicians could give to patients with diabetes. This informational sheet covered the definition, prevention, treatment, complications, prevalence, diagnosis, online resources, and risk factors of diabetes. The point here was to increase patient’s knowledge in order to empower them against their disease. Hopefully, with this knowledge base, patients could take an active role in controlling their diabetes and preventing complications.

Methamphetamine Use and Manufacturing in Lebanon, Oregon
Date of project: 7/7/2003

For my community project I analyzed the problem of methamphetamine (meth) use in Lebanon. I was really interested in this topic because I know nothing about this drug and it is one of the most popular drugs in Lebanon. At the clinic I saw a number of patients who were meth addicts and was told by the doctors that its use and manufacturing is a significant problem in the community. The demographics of Lebanon include a very low socio-economic class of people who are either blue-collar workers or unemployed. Meth is cheap and easy to make and therefore tends to be very prevalent in rural towns like Lebanon. My goal in doing this community project was to find out what meth is, how it affects the body, how it is made, the prevalence of the problem and the options for treatment once a person becomes addicted. In order to answer these questions, I did extensive research on the Internet regarding general information about meth and its manufacturing; I interviewed a detective who works with the local drug enforcement program in Lebanon, and I interviewed a counselor who works at ACES, the only drug treatment center in Lebanon. Through these experiences, I was able to learn a wide range of information regarding meth. The following information is a summary of what I learned from my research.

The Potential Benefit of Electronic Medical Records In the Management of Chronic Illness: A Case Study of Coronary Heart Disease and Depression in Lebanon, Oregon.
Date of project: 3/24/2003

In recent years electronic medical records (EMR) have become an increasingly important part of documenting and providing medical care. In addition to saving money, reducing errors, and improving documentation, EMRs can potentially improve patient health by allowing physicians to better monitor patient progress and increase information access to patient populations. This report was designed use a patient population in Lebanon, Oregon as a case study to gain an understanding of how EMR could affect the care provided for a chronic medical condition. The paper charts of 62 admissions (97% of the total) coded for acute myocardial infarction at Lebanon Community hospital for the year 2002 were selected as markers for coronary heart disease (CHD). These were reviewed to determine the prevalence of a comorbid diagnosis of major depression or medical treatment of depression. Depression is a major risk factor for increased severity and mortality in cardiac events, therefore managing depression can have a significant impact on patient outcomes. This study found that 15-19% of patients hospitalized with an acute myocardial infarction were either diagnosed or being treated for depression. However due to systemic barriers it was difficult to efficiently assess patients’ long- term history and to evaluate whether depression in these patients was successfully being treated. This was because information was often missing from charts, hospital and outpatient records were not integrated and documentation was often incomplete. The Samaritan Health System that provides care in Lebanon is part of a network of five hospitals and 21 outpatient clinics. This system would likely receive more benefit from an EMR through greater efficiency and better quality control and decision-making support than the initial cost of installation, training and conversion of old records

Community Response to Loss of Pharmacy Benefits for Patients with Schizophrenia in Lebanon, Oregon
Date of project: 2/10/2003

Recent budget cuts have led to the loss of pharmacy benefits for certain Oregon Health Plan patients. People with schizophrenia were identified as a group particularly vulnerable to deterioration and increased complications without medication. The purpose of this project was to examine the resources available to address this crisis in Linn-Benton counties, and Lebanon specifically. Community response included creation of a generic formulary and a medication assistance program, despite lack of government funding. Resources in Lebanon for this population are substantial. The primary shortcoming was dependence on pharmaceutical company patient assistance programs for patients who require atypical antipsychotic medication.

Methadone Maintenance Therapy: An evaluation of health benefits, cost-effectiveness, social impact.
Date of project: 12/30/2002

BACKGROUND: Injection drug use in the United States is a significant cause of morbidity and mortality, increased health care costs, and criminal behavior. While methadone maintenance therapy (MMT) reduces criminality, health care expenditures, and morbidity and mortality among injection drug users and the general population, economic, social and political barriers prevent its universal funding. The purpose of this review was to examine the cost effectiveness, effect on morbidity and mortality, and effect on criminality of MMT in order to help determine whether MMT should be covered by health care plans. METHODS: A literature review was conducted to determine the cost effectiveness of MMT with respect to morbidity and mortality, criminal behavior, and survival as measured by overall survival and quality-adjusted life-years. RESULTS: Among a population of drug users and non-users, methadone maintenance treatment leads to significantly decreased health care costs, decreased morbidity and mortality, and has a cost per quality-adjusted life-years that is well below many other accepted medical interventions. CONCLUSIONS: Methadone maintenance treatment is cost-effective on the basis of commonly accepted criteria for medical interventions. Funding MMT is a cost-effective investment by health care plans that should lead to long term monetary savings and increased quality-adjusted life years among the entire population.

Barriers hindering the use of Emergency Contraception in Lebanon, OR: Patient Access, Knowledge, Perceptions, and Attitudes
Date of project: 11/4/2002

Each year, approximately 3.18 million women in the United States experience a pregnancy that is unintended at the time of conception, constituting 53% of all pregnancies. Similarly, in Oregon, 53% (n-31, 899) of all pregnancies in 1999 were unplanned. Located in Linn County, Lebanon consistently contributes to a county annual pregnancy rate that is among the highest in the state. While typically considered a problem afflicting teens and unmarried women, unintended pregnancy extends to all demographic groups: 77% of women over 40; 40% of married women; 82% of teens ages 15-19; and 88% of never-married women report pregnancies unintended at the time of conception. As a means to prevent pregnancy from occurring after unprotected intercourse has taken place, the Emergency Contraceptive Pill (ECP) is a safe and effective preparation that reduces the likelihood that a pregnancy will occur by 75-89%. In other areas of Oregon as well as nationwide, ECP has been touted as an effective means of decreasing the incidence of unintended pregnancy and its associated burdens. However, a recent local survey of female patients indicates that women in Lebanon know very little about ECP; consequently, one may surmise that it is a rarely used method of contraception. To investigate why ECP is seldom used in this area, this project consists of two parts; (1) an assesment of patient access to ECP information and prescriptions as a function of availability; and (2) a questionnaire administered to women ages 14-44 presenting to Family Practice and Internal Medicine clinics to assess patient knowledge, perceptions, and attitudes concerning ECP.

Adoption and Rural Family Practice
Date of project: 9/23/2002

Adoption is an important option to be considered by mothers who are facing unplanned pregnancy. Often women who are unprepared on several fronts for parenthood and who have neither access to nor acceptance of abortion as an option are not introduced to this third and vital possibility for their child. Current societal views and lack of physician education may limit how often it is discussed, especially within the scope of a rural family medicine practice. This project examined the current climate regarding adoption in Lebanon/Sweet Home and attempted to gather information on physician/counselor education and readiness to offer adoption as an option to their patients/clients. One-on-one interviews, journal research, and a survey distributed among family medicine and OB-gyn physicians, adult and family service counselors, and school guidance counselors were employed to gather information. It was evident that there is much work to be done in providing instruction and information about adoption to those on the front lines of dealing with unplanned pregnancy

Assessing the needs of adolescence in a rural community with a high rate of teenage pregnancy.
Date of project: 8/12/2002

This project aimed to assess the needs of adolescence in a rural community with a high rate of teenage pregnancy. Although the rate of teenage pregnancy and births has been declining across the U.S. and Oregon over the last decade, there are still many counties in Oregon that are disproportionately affected by this social burden. Linn county (as a rural community) has the highest rate of teenage pregnancy and births. This project tries to unravel the mystery of how we can best target teens with useful information that they want to hear and will further utilize. The project lead to numerous discussion groups with over 100 high school students. The results show that in the area of sex and pregnancy teens are concerned about their comfort level with the person discussing these issues and the relevance of these issues to their lives. Therefore, the most effective form of education for teens on pregnancy prevention would be one that incorporates a peer provider model into a comprehensive education program.

Proposal for a Clinical MultiTool
Date of project: 7/1/2002

Deep tendon reflexes are routinely tested using suboptimal methods due to the lack of readily available reflex hammers in a Lebanon family practice clinic. Physical exam findings are therefore highly variable and lack credibility. A novel tool is suggested and described which combines a folding reflex hammer with other essential tools of the neurologic exam in an easy to carry package. Physician feedback is positive and suggests that the tool would be embraced and used by a group of physicians who would otherwise neglect an important aspect of the neurologic examination. Direction for future development is discussed.

Smoking Cessation Intervention in Lebanon, OR: Development of a Patient Handout for Augmentation of Clinic Intervention
Date of project: 2/11/2002

Smoking continues to be a major medical issue in the United States. This study attempted to identify the effectiveness of smoking cessation intervention and community resources in a Lebanon, Oregon family practice clinic. The design was observation of family physician's interaction with patients who smoke throughout the course of a six week rotation in a higher prevalence setting. A smoking cessation class run by respiratory therapy at the community hospital is the primary source for referral if a patient is interested in quiting. This program was contacted for both interview and observational analysis. Finally, patient handout effectiveness and readiness in the clinic was observed. Whereas there seemed to be a mechanism in place to identify patients who smoke, specific intervention for smoking cessation was dependent on having symptoms or concerns directly related to side effects of smoking. Further, the only handout readily available for patients was the smoking cessation class handout. Therefore, the final product of this project was development of a patient handout for those in the pre-contemplative and contemplative stages of decision making to aid in smoking cessation counseling in a time limited clinical setting.

Knowledge Is Power: Rural Women's Access To Contraceptive Information.
Date of project: 1/2/2002

Despite advancements in contraceptive technologies over the past two decades, unintended pregnancy, particularly teen pregnancy, rates remain high in the United States compared to other industrialized nations. Almost half of all pregnancies in the U.S. each year are unintended. Numerous factors contribute to this problem, many of which are personal, political, economic, or cultural in nature. Providing information is not the only way to increase women's contraceptive use. There are other barriers to care that have as much or more of an impact on access, particularly in the rural setting. But lack of information is not a very difficult obstacle to overcome if it is acknowledged and addressed. Contraceptive knowledge is one of the few modifiable risk factors for unwanted pregnancy. This project consists of three components: assessing patient access to contraceptive information and services, taking action to improve access, and recommending changes that may benefit some patients.

Hepatitis C in Lebanon, Oregon: Development of a patient handout to connect patients with Hepatitis C with available community and national resources.
Date of project: 5/6/2002

Hepatitis C accounts for 20% of acute viral hepatitis, 60-70% of chronic viral hepatitis, and 30% of cirrhosis, end-stae liver disease and liver cancer. Although 1.8 million Americans are infected with Hepatitis C, many do not know much about the route of transmission of the disease, long-term consequences of the disease, and available resources. The purpose of this study was to investigate the usefulness of a short, concise handout to patients in a clinical setting. The methods of the study included searching the internet and community for existing resources available to patients in Linn county. A handout was then formulated containing this information and dispersed to the Mid-Valley Clinic as well as the Free Clinic in Lebannon, Or. Although the physicians were well educated in Hepatitis C and had a lot of information available about Hepatitis C, there was no single handout available for patients containing both key information abour Hepatitis C and community resources available to them. Therefore, a handout was formulated and dispersed.

Diagnosis And Management Of Attention Deficit Hyperactivity Disorder Among Children And Adolescents Below The Age Of 14 In A Rural Community Primary Practice.
Date of project: 9/24/2001

Attention Deficit Hyperactivity disorder (ADHD) is the most common neurobehavioral disorder of childhood. It is also among the most prevalent chronic health conditions affecting school-age children. ADHD occurs in 3 to 5% of school-aged children, accounts for as many as 30% to 50% of children referrals to mental health services, and results in substantial impairment in peer, family, and academic functioning. Given the paucity of child mental health providers both in urban and rural settings, primary care providers - family medicine physicians and pediatricians - play an important role in the initial diagnosis as well as subsequent management of children and adolescents with ADHD. They recognize behavior problems that may impact academic achievement in 18% of school-age children seen in their offices and clinics. Hyperactivity or inattention is diagnosed in approximately 9% of the latter. In this light, the projects focuses on: Current practice guidelines on the diagnosis and management of ADHD among school-age children and adolescents below the age of 14; Chart review of a sample of fourteen patients followed by three family practitioners in Lebanon, Oregon for baseline data of time of diagnosis, treatment regimen and frequency of follow; Availability of school-based resources, and a number of proposed future steps towards improvement of the latter services and resources in primary care settings.

The Rural Epidural: Looking at Protocol-Driven, Nurse-Managed Epidural Anesthesia in the Rural Setting.
Date of project: 11/5/2001

Rural location and financial constraints make it difficult to provide 24-hour in-house anesthesia coverage for elective obstetric epidurals at Lebanon Community Hospital (LCH). To ease this burden, LCH shares call with Albany Anesthesia Group (AAG). AAG agreed to take call under the condition that for elective epidural anesthesia, the anesthesiologist/anesthetist will place the catheter but the labor and delivery nurses will manage and adjust the epidural via physician-designed protocol. Labor and delivery nurses at LCH are uncomfortable with this agreement as the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN) states that this falls outside of the scope of practice of a labor and delivery nurse. Practicing outside of ones' scope leaves the nurse vulnerable to individual litigation, loss of licensure and threat of termination. The Oregon State Board of nursing has yet to formally rule on this issue. In the meantime, labor and delivery nurses at LCH have been trained to manage epidural anesthesia via protocol and have been doing so for the past six months. To date, no objective measures have been documented to monitor safety and efficacy of this practice. This study looks at current documentation standards and recommends specific measurable events to collect for further study.

A Newly Opened Urgent Care Walk-in Clinic in Lebanon, Oregon: Improving Access or Providing a Safety Net.
Date of project: 8/13/2001

Access to routine health care can be difficult in some rural communities for several reasons, these include a shortage of primary care physicians, lack of a facility, lack of insurance, etc. As a result, patients have to use Emergency Departments for care that is not emergent. To provide a more affordable alternative, Lebanon Community Hospital opened an Urgent Care within the hospital. This study is a cross-sectional study to assess the patient population that is using a rural Urgent Care. The results of this study indicate that this particular Urgent Care is being used for its intended purpose of improving access for patients who are unable to be seen by a PCP. Although there is a segment of the population who do not have a PCP or insurance, the Urgent Care is providing an alternative to the more expensive emergency department visit.

Hepatitis A and B Vaccines in People Infected with Hepatitis C Virus
Date of project: 7/2/2001

This project looks at the treatment of patients infected with HCV by doctors in primary care as compared with national guidelines and specifically evaluates the number of patients vaccinated for HAV and HBV. This was done by review billing records for primary diagnosis of Hepatitis C seen by Mid-Valley Medical Plaza in Lebanon, Oregon over a 2.5 year period and reviewing the injection procedures for each patient. Secondly, a questionnaire was used to interview physicians at MVMP regarding their approach to the management of patients with Hepatitis C. Records showed that only 14% of patients studied had received vaccines for Hepatitis A and 8% had received vaccines for Hepatitis B. The questionnaire demonstrates a uniform approach to the treatment of Hepatitis C using the national guidelines with the exception of vaccinations although, all physicians said they vaccinated their patients. The report reviews the frequency of adult vaccines and the importance of reminders in assuring better vaccination coverage. Recommendations are then made to use reminder sheets and suggest the plausibility of a Hepatitis C clinic to improve delivery of vaccines.

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