RCHC Community Project Abstracts

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Providing Successful Comprehensive Outpatient Health Care
Date of project: 10/12/2009

With increasing information about the evidence-based benefits of preventive measures, and as the number of recommended vaccines, screening labs and exams, and behavioral and lifestyle screening expands, the daily workload for a family physician also increases. Heightened demands on the crucial face time we have with patients mean we need to find a way to complete all the tasks and meet all the goals of a clinic visit while maximizing our time, energy, and resources. One of the most significant things I witnessed during my rotation was the efforts of the office staff to keep up with expectations and workload. I chose to help the Scappoose clinic develop a more efficient way to implement screening tools without having patients fall through the cracks. In my research, I came across an approach for quality improvement that involves multiple steps. The steps involve understanding the current workflow, identifying the goals, coming up with ways to make changes that will help meet the goals, and developing ways to measure improvements.

Chronic opiate therapy in the rural setting: special considerations and concerns
Date of project: 9/7/2009

Chronic opiate use represents a challenge for rural providers. These patients often have pain with no treatable cause and may be high utilizers of clinical time. In the absence of pain and addiction specialists, it falls to the family doctor to manage these issues. There are many resources available to providers including online pain management recommendations and recently the Oregon Senate recently passed Bill 355 creating a controlled drug database. This project explores the role of this new program in the development of a standardized pain agreement and the management of these patients in the clinic.

Vitamin D Explained: Question and Answer Handouts
Date of project: 8/3/2009

Vitamin D deficiency or insufficiency is estimated to be a common condition in the U.S. population. Long-term bone health is the most common context for vitamin D deficiency discussions, but there is a growing body of literature associating vitamin D deficiency or insufficiency with other health issues including cardiovascular disease, fall prevention, cancer, multiple sclerosis, depression, diabetes, hypertension, all cause mortality, and health costs. The prevalence of vitamin D inadequacy, and the associated health concerns, in combination with my own experiences, has led me to conclude that public knowledge regarding vitamin D could be improved. In an effort to help patients educate themselves, as well as solidify my own understanding for use in patient encounters, I developed two vitamin D question and answer handouts for use by patients and/or providers; one in brief and one with more detail including references for people wanting additional information. These handouts include a basic overview of vitamin D function, health considerations, deficiency/insufficiency risk factors, deficiency/insufficiency prevalence, dietary sources, and intake recommendations.

Teen Driving Safety in Scappoose and Columbia County
Date of project: 4/27/2009

Motor vehicle accidents (MVA) are the leading cause of death for young people in the United States and Oregon. Teen driving safety has received increased attention in recent years from national healthcare bodies such as the American Academy of Pediatrics (AAP) which recommends that primary care physicians educate teenage drivers and their parents regarding risky teen driving behaviors. Statistical analysis as well as interviews with local residents of Scappoose and Columbia County indicated the need for such a primary care educational initiative. Following the recommendations of the AAP, an educational handout was formulated providing information on teen driving risk factors and ways to avoid them. Also included was a driving contract designed to be used by parents when talking with their teen about driving risks. This contract establishes a set of restrictions on driving consistent with a Graduated Drivers Licensing program with associated punishments for bad behaviors and rewards for good behaviors. These materials were made available to patients frequenting the clinic as part of a well or ill visit and are intended to be used in the same manner as other preventative educational materials such as handouts on tobacco avoidance, guidelines for good diet and exercise, and safe sexual practices. It is hypothesized that education on the dangers and risks of teenage driving directed at parents and teens as part of a medical visit in the Scappoose OHSU Family Medicine Clinic with a physician or other healthcare provider is an important step in reducing injury and death related to MVA in the community

Improving Nutritional Awareness among Pregnant Teens in Columbia County, OR: Design of a Patient Handout on “Eating Right in Pregnancy”
Date of project: 3/16/2009

Teen pregnancy continues to be a controversial issue in the United States. A recent increase in the national teen birth rate in 2006 and 2007 may be reflected in the recent “epidemic” of teen pregnancies in Columbia County. Pregnant teens frequently present later for prenatal care and are more likely to suffer from nutritional deficiencies, failure to gain appropriate weight, and higher smoking rates associated with medical complications such as poor maternal weight gain, maternal anemia, low birth weight, prematurity, and developmental disabilities. Recent studies have suggested that many of these medical issues can be resolved when teens receive adequate prenatal care. This study focused on increasing nutritional awareness among pregnant teens in Columbia County as a means of improving pregnancy outcomes. The attitudes of local girls towards body weight and dieting suggest that they may be at risk for nutritional deficiencies and failure to gain appropriate weight during pregnancy. This was an observational study of resources available to teens in the OHSU Family Medicine Clinic in Scappoose, OR, including prenatal visits and one-on-one childbirth education. A review of the literature on teen pregnancy and nutrition during pregnancy was also combined with an examination of statistics on local teen pregnancy and birth rates as well as attitudes of 11th-grade girls towards body weight and dieting. A handout on nutritional issues was created written for a tenth-grade reading level and intended to be provided to pregnant teens during prenatal visits.

Teen Pregnancy in Scappoose, Oregon and the Creation of an Educational Brochure Describing What to Expect and Available Resources for Pregnant Adolescents.
Date of project: 12/29/2008

Although teen pregnancy rates have been declining in Columbia County since 1996, nearly 1 in 4 (23.5%) births are still to adolescent mothers aged 15-19 (1,2,3). Young woman in Columbia County face multiple challenges including higher rates of drug and alcohol use, lower economic status, earlier sexual debut, and most importantly lack of sexual education (4,5). During my clerkship in rural family medicine at OHSU’s Scappoose clinic, I saw many pregnant teenagers and was quite surprised by the questions they asked. The young woman that I saw had no idea what to expect, they did not know what resources were available to them, and some didn’t even understand their own anatomy. While researching this topic, I found that there is a great deal of effort being made in Scappoose (and Oregon as a whole) to convince parents that sexual education is important and to create curriculums that teach adolescents about safety and prevention. Prevention is always the best strategy when trying to combat health problems and I therefore understand why so much attention is being paid to prevention in the case of teen pregnancy, there is however less effort being focused on young woman who have already become pregnant. After identifying that education and resources for pregnant teenagers is an area of intense need in Scappoose, I set out to create a simple one to two page brochure that would answer common questions and concerns as well as list resources that would be helpful to young pregnant woman. Information to be included in the brochure was determined by talking with the young woman themselves and also through conversations with the physicians and nurses who take care of these woman at OHSU’s Scappoose family medicine clinic. This brochure will be handed out to pregnant teenagers who come to the Scappoose clinic for prenatal care, or those who attend the clinics prenatal classes.

Prevention of Osteoporosis Across the Lifespan
Date of project: 10/13/2008

Osteoporosis is a major public health concern, affecting an estimated 10 million Americans and costing the American healthcare system close to $19 billion1. Though the diagnosis of osteoporosis typically does not come until after age 50, research has shown that prevention of the disease must begin far earlier than this. In an effort to promote prevention earlier in life, and thus hopefully decrease the prevalence of osteoporosis in generations to come, I preformed a review of the literature on evidence for preventive measures throughout the lifespan. These prevention guidelines were then incorporated into “smart phrases” in the electronic medical record, which could be entered into the patient instructions area with the ease of a couple key strokes. No longer would there be a need to have clinicians memorize the recommended calcium intake for a 3 year old or what type of activities are recommended to help build strong bones. Now the clinicians could simply enter the pre-written smart phrases into the patient instructions area and have the information easily at hand for both themselves and the patient. Not only will this help educate the patient on what they can do to prevent osteoporosis but it facilitates a discussion between the clinician and the patient about risk factors and what the patient can do now to prevent the disease. Thus far, the clinicians in the Scappoose medical clinic like the idea of these smart phrases. Many of them agreed that it was difficult to know what guidelines or evidence was out there concerning osteoporosis prevention early in life. They appreciate these smart phrases for putting that information at their fingertips. Future research that could stem from this project includes assessing how useful these smart phrases actually are, how often they are actually utilized by clinicians and if in fact they helped to decrease the incidence and prevalence of osteoporosis in future generations.

Obesity in Scappoose, Oregon: Developing a patient handout about the benefits of a Mediterranean Diet
Date of project: 9/8/2008

Obesity and weight-related diseases (hypertension, diabetes mellitus, and hypercholesterolemia) are major medical problems in the United States. This study was initiated to design an educational handout to assist patients in making beneficial nutritional changes to combat these diseases. The study consisted of an observational period to assess patients’ needs, difficulties, and constraints during this process, as well a period of research and development to create a pamphlet to best address these requirements. During the latter phase, strong research was found proving that the Mediterranean Diet was beneficial in addressing these diseases. The final period of the study consisted of a distribution phase to share the new material with the patients and gauge the impact of the handout. More research needs to be done regarding how the pamphlet influenced the patients, and would reveal specific strengths and weaknesses.

A Brief Sojourn in the Land of Chronic Pain Medication, as experienced at Scappoose Family Medicine
Date of project: 8/4/2008

A recent article in the New York Times detailed the increasing use of methadone for chronic pain in the primary care setting. Often considered by the public as a drug for drug addicts, it is an opioid similar to the prototypical opioid morphine. However, methadone has substantially different pharmacokinetics, and these properties may make the drug dangerous to certain patients. Still, the increase in methadone use continues, likely due to its lower cost relative to other extended-release opioid formulations. Does this pose problems for primary care patients with chronic pain and public benefits such as CareOregon? Does it pose problems for providers who are unaccustomed to or uncomfortable with methadone's pharmacokinetics? Though this short study cannot answer these questions definitively, by considering the patients of OHSU Family Medicine Scappoose, we can learn about chronic pain medications and their use. We also can glean some providers' opinions regarding the prescription of methadone, and the restrictions that they face due to many patients having public benefits. Finally, we may remind ourselves as clinicians that hidden dangers lurk for patients starting methadone, or for those converting to methadone from another opioid.

Portion Size? Serving size; Teaching Healthy Living Choices in Scappoosereatment of Chronic Pain
Date of project: 6/30/2008

Obesity is a growing epidemic in the United States of America. This along with low health literacy, especially in rural areas, leads to increased obesity in these areas. Rural areas also suffer from physician shortages making the time spent with patients more and more valuable. The goal of this project was to make the most of time spent at the doctor’s office to educate obese patients about portion control. The design was a PowerPoint presentation about how food portions and therefore caloric content has changed over the past 20 years. This presentation also included information about exercise requirements to burn these extra calories. In order to maximize the time spent at the doctor’s office, the presentation was set up to run on the computer in each exam room while the patient waited for the doctor at OHSU’s Family Medicine Clinic in Scappoose, Oregon and was shown to 15 obese patients.

Feasibility Study of Vitamin K Supplementation to Treat Patients with Unstable Anticoagulation on Warfarin at the Scappose Family Practice Clinic
Date of project: 4/28/2008

The management of warfarin therapy affects a large segment of the aging population and is expensive and time consuming for the patients and clinicians. For many of the patients at the Scappoose Family Practice Clinic, it was a financial hardship to take time off work, find transportation and pay a $20 co-pay each time they needed their Warfarin dose adjusted. This is in addition to the financial and medical devastation such as stroke or hemorrhage that could result from a patient being under or over anticoagulated. The purpose of this community project was to design a study to test the hypothesis that 150mcg of daily Vitamin K could stabilize patients on warfarin in an INR range of 2-3 and reduce the frequency of warfarin dosage adjustments. Phase I consisted of a literature search and then based on previous studies developing inclusion and exclusion criteria which would be used to identify a subset of patients at the Scappose Family Practice Clinic who would be eligible for this study. Once these patients were identified, a retrospective chart review was done collecting data on these patients for the period 11/1/07 - 5/1/08. Phase II will involve giving these patients 150mcg of daily vitamin K and collecting data for 6 months. We will then compare the two data sets. If the results indicate that 150mcg daily vitamin K improves anticoagulation control in patients with unstable INRs, this protocol can then be initiated to the benefit of the patients and the clinic.

Infant and Children's cough and cold medications - a handout for parents
Date of project: 3/17/2008

The common cold, while a limited minor illness, is a frequent source of distress in new parents of infant children and accounts for millions of doctor visits. Children can average 6-8 colds a year. Over-the-counter children's cough and cold medications have been associated with visits to emergency departments and death in children under the age of 2 years old and as a result are no longer recommended for children <2 years old. Educating parents on the appropriate treatment of cold symptoms in their infant can reduce the use of cold medicines and adverse events from cold medicines. This study reviewed risks and benefits of cold medicines and other non-pharmacologic treatment options and appropriate recommendations were compiled in a patient handout.

Adult Obesity in a Rural Clinic: Prevalence, Comparison and Weight Reduction Strategies
Date of project: 2/11/2008

The prevalence of obesity in the US has doubled in the past two decades so that now, almost two out of three adults are either overweight or obese[1]. This epidemic of excess body fat is a major public health concern since it leads to a higher risk of premature death, type II diabetes, hypertension, dyslipidemia, coronary heart disease and other serious diseases and health concerns. The state of Oregon is not immune to this epidemic, by no means. Although less obese than the U.S. average, more than 1/2 of the state’s population is either overweight or obese[2]. Upon investigating the prevalence of overweight/obese at a rural health clinic in Scappoose, OR, however, it was determined that the prevalence there was much worse than either the overall state or nation values - over 50% of clinic patients were obese and more than 3 out of 4 patients were either classified as overweight or obese. In order to begin to reverse these numbers, it was determined that a need existed to put together a concise resource, available to the clinic staff and patient population, to help increase awareness of all the resources for weight reduction strategies that can be safely used to achieve and maintain a body weight that optimizes health.

A Study of Specialty Referral Patterns from Scappoose Family Practice
Date of project: 12/31/2007

Patients are referred from Scappoose Family Medicine Clinic to specialty practices which are usually located in Portland, 20 miles away. Accessibility to specialists and coordinating care with specialists for patients is cumbersome and time consuming. This study was undertaken to help determine feasibility for a specialist to visit Scappoose clinic at a reasonable frequency. Referral information was collected from the business office of the clinic. The study determined that orthopedics surgery was the most referred specialty with 6 patient referrals per week and physical therapy (PT) was the most referred service also with 6 patients per week. While PT is well supported in Scappoose, a weekly orthopedic clinic would better serve the needs of the community. However, a pre-requisite for a viable orthopedic clinic, with quick turnaround, is an onsite x-ray facility. No data exists that indicates the number of x-ray images that are ordered by the providers at the Scappoose clinic. To support the volume of patients, about 350 – 400 patients per week, it is certainly feasible to have an x-ray machine.

Efficacy of Emergency Medical Systems for transport of patients to Portland hospitals and appropriateness of prehospital treatments at the OHSU family medicine clinic in Scappoose
Date of project: 10/15/2007

Columbia County has a population of 46,220, 5 family practitioners, 8 general internists, 14 nurse practitioners, 5 physician assistants and no hospitals. OHSU's family medicine clinic in Scappoose and Legacy's urgent care center in St. Helens, provide the lion share of the health care in the area. However both clinics have limited resources and capabilities in providing emergency care. Patients are often transferred either by Emergency Medical Services (EMS) or private cars, 20 miles away, to hospitals in Portland metro area. The transport on average takes about 30 minutes, time that could be crucial in determining the patient outcome. It is thus important to provide all the appropriate tests and treatments to the patients, especially those with suspected myocardial infarctions, prior to the lengthy transport in order to limit the degree of damage and negative outcomes.

Utilization of the Emergency Medical Systems for Transfer of Patients to Portland Hospitals at the OHSU Family Medicine Clinic in Scappoose.
Date of project: 9/10/2007

Rural health clinics serve a vital role in providing health care to areas where there are often few options; providers in these areas must often perform a greater variety of procedures with fewer resources than might be desirable. However, there are occasions when a patient must be transported to a hospital where additional resources required for his/her care are available. Scappoose, Oregon is located roughly 20 miles north of the nearest hospitals which are found in Portland. The Emergency Medical Systems and Fire Department of Scappoose are responsible for providing emergency response for a 100 square mile area as well as transferring patients from the OHSU family medicine clinic to Portland hospitals whenever the need arises. The Scappoose EMS consists of three ambulances, three career firemen, and any available volunteers. To better evaluate the utilization of the EMS for patient transfer of the Scappoose Family Medicine clinic, a thorough form for recording that data into a centralized record has been created.

Cardiac Arrest: Changing Resuscitation Guidelines to Increase Participation, Improve Survival Rates and Extend Community Resources
Date of project: 8/6/2007

Each year, several hundred thousand Americans die as a result of cardiac arrest despite several decades' worth of training in cardiopulmonary resuscitation. Widespread confusion about when and how to implement resuscitation protocols, distaste for certain aspects of the procedure, and declining confidence in its potential for success contribute to a lack of bystander participation and resultant strain on local emergency resources. A handout has been prepared to reflect current research on the subject and provide an opportunity for further discussion. Small steps such as this may help to reintroduce the topic of cardiac resuscitation to the lay public, particularly if new guidelines are easier to understand and implement.

Prevalence and patterns of breastfeeding in Scappoose, Oregon: Development of two handouts
Date of project: 7/2/2007

The decision of mothers whether or not to breastfeed their infants has historically been influenced by trends and attitudes within our society rather than by an understanding of the benefits of breastfeeding. Lack of support by the partner or family has been demonstrated to be a major barrier for mothers to continue breastfeeding. This study examines the prevalence and pattern of breastfeeding among infants presenting for well-child exams to the OHSU Family Medicine Clinic in Scappoose, Oregon. The design of this study utilizes both quantitative and qualitative methods and included patient data base research, interviews with providers, childbirth educators and the WIC program nurse as well as observation and direct participation in prenatal and postpartum care clinics and a 4-week childbirth education class. The participation in the clinics and the class allowed for direct patient education opportunities and instruction on breastfeeding techniques. From the findings, two patient handouts were created, one explaining the benefits of and myths about breastfeeding, the other given detailed instruction on breastfeeding techniques and partner support. The handouts were available during the final days of the rotation and will assist the clinicians whenever women request information on breastfeeding during their visits to the clinic and serve as a guide to one-on-one instruction about breastfeeding techniques. In addition, they are to be made available during subsequent childbirth education classes and to provide a framework for future breastfeeding classes.

A Closer Look at the Nutritional Habits of Scappoose High School Students
Date of project: 4/30/2007

Obesity has become increasingly prevalent among school-aged children and adolescents in the United States. With obesity becoming increasingly more widespread in the U.S., especially amongst the rural population, it is probable that adolescents in their high school years will reflect this same trend. This study examines the attitudes towards nutrition of Scappoose High School students who do and do not participate in an athletic activity in Scappoose, Oregon. A survey was formulated which gathered information on their opinions on the cafeteria foods as well as on the impact of athletic or physical activity on nutritional choices. At the present, nutritional education for the general Scappoose high-school population is limited to a part of the Health class curriculum. At the clinic, nutritional habits are checked when adolescents come in for a sports physical exam. Otherwise, there was no established presentation of the nutritional values of the food offered by the school or the benefits of physical activity on their health. The results of this survey will be given to the athletic director and health class instructor to aid in their understanding of their students views on nutrition.

Striving for Healthier Children: A Closer Look at the Scappoose School District’s Local Wellness Policy
Date of project: 3/19/2007

The prevalence of obesity and its associated diseases in the U.S. has been increasing over the last decades at an alarming rate. The OHSU clinic in Scappoose was noted to have a particularly high prevalence of obesity amongst its adult patient population. Obesity rates in the U.S. of young children have doubled and that of adolescents have tripled over the past twenty years. Prevention is the most effective tool in reversing the obesity epidemic, as well as increasing overall health, and generally the earlier the intervention, the more potentially effective it is. One particularly important site for prevention measures are the public schools, since children often receive most of their nutrition, exercise, and lifelong nutritional and physical education at school. Three years ago, the federal government signed into law an act that requires each local education agency or school district participating in the National School Lunch Program and/or School Breakfast Program to develop a local wellness policy that promotes the health of students and addresses the growing problem of childhood obesity. This project focuses on analyzing and discussing the Scappoose school district Local Wellness Policy along with some of the major obstacles to its implementation.

Death with Dignity - a rural community's perspective
Date of project: 2/12/2007

Context: End of life care is a subject that has become more important over the last decade. “Death with dignity” is often a phrase that is used when discussing quality end of life care. However, this phrase is still not well defined. Furthermore, end of life care has been recognized as an ethical obligation of health care providers and caregivers, but this concept has not been examined from the perspectives of residents of rural communities. Objective: The objective of this project is to identify and describe elements of quality end of life care from the perspectives of residents living in the rural town of Scappoose, Oregon, as well as determining the level of awareness of advanced directives and POLST forms amongst those residents. Methods: This study is a qualitative study conducted using face-to-face interviews with open-ended questions. A total of 45 participants from 2 patient groups: clinic patients (n=28) and residents of a long-term care facility (n=17). Results: The participants identified eight domains of quality end of life care: avoiding inappropriate prolongation of dying, receiving adequate pain and symptom management, achieving a sense of control, having a peaceful and comfortable death, relieving burden, knowing that they are going to heaven, and not being alone. Overall, less than 50% of the participants in this project were aware of POLST forms. Conclusion: The conclusions drawn from this project are that the domains identified, which characterize a rural community’s perspective on end of life care, can serve as points for improving quality end of life care. Some of the values held by residents of Scappoose may also give insight as to how those residents have defined “death with dignity.” This project has also revealed the lack of awareness of POLST forms amongst the rural community of Scappoose, expressing a need for increased education regarding POLST forms and end of life care.

Expanding Anticipatory Guidance in Columbia County
Date of project: 1/1/2007

Columbia County has seen a significant increase in recent years in the number of single mothers with children younger than 5 living below the poverty level. Many parents in the community lack resources and access to parenting information. Various programs in the county provide services to young mothers and children, including Head Start, Healthy Start, and WIC. In addition, the OHSU Family Medicine Clinic at Scappoose serves patients primarily from Scappoose and St. Helens, the largest towns in the county. Providers in all facilities expressed a need for simple hand-outs to give to parents with anticipatory guidance and advice about parenting for children of different ages. Handouts were created with guidance for all well-child visits from ages 2 weeks to 5 years. Guidelines focused on age-specific information about nutrition, development, and safety. The materials were distributed to providers at the Scappoose Clinic and program directors for Columbia County Head Start, Healthy Start, and Columbia County Department of Public Health, which coordinates the county WIC program.

Implementing Nurse Visits for Prenatal Care in Scappoose Family Medicine Rural Health Clinic
Date of project: 10/16/2006

Prenatal care provides benefits of reduced incidence of low and very low birth weight babies, reduction of infant mortality, and decreased rates of preventable maternal complications during delivery. In Columbia County, there are two main sources of prenatal care, only one of which is provided by MDs. The goal of this project was to help to implement the vision of restructuring the way prenatal care is given at Scappoose Family Medicine Clinic to include once a trimester visits to a trained nurse who will discuss things to expect in the upcoming trimester, answer questions about common pregnancy complaints, and provide a packet of resources specially designed for the current trimester.

Understanding Chemical Dependency as a Family Illness: Ways to Help in a Rural Primary Care Facility
Date of project: 9/11/2006

Misconceptions about drug and alcohol addiction abound in American society. Addiction is a brain disease as shown by neurobiological studies. However, most Americans, even physicians, view it as primarily a moral or personal weakness. Families need to be educated about the causes of addiction, but they also need to understand their roles in helping their loved ones. Resources for addicts are available, but often the effects of chemical dependency on the family system are overlooked. My project’s concrete goals were to educate the staff about addiction, as well as to develop some handouts they can give to families suffering from a loved one’s addiction. Abstract goals were to help families: 1. Understand chemical dependency 2. Accept chemical dependency as a family illness 3. Embrace self-acceptance 4. Commit to a continuing recovery program 5. Identify local resources

Improving Anticipatory Guidance in Rural Family Medicine
Date of project: 8/7/2006

Anticipatory guidance is considered an important component of well-child care. Many adverse outcomes to pediatric populations are easily avoided with adequate and effective anticipatory guidance. The purpose of this project was to investigate the current practices of providing anticipatory guidance employed by health care providers at the OHSU Family Medicine at Scappoose clinic, and to seek ways of improving parental education and implementation. This project seeks to improve anticipatory guidance in rural family medicine through the development of handouts providing information for parents that correlates with verbal guidance given during the well-child visits from birth to 2 years of age. Providing good anticipatory guidance is an effective and important way to encourage health and safety in the pediatric population.

Attempts to Document Healthcare Perceptions and Expectations of Scappoose Oregon Residents
Date of project: 7/3/2006

This study intends to document the perceptions and expectations of healthcare in the rural community of Scappoose, Oregon for use in future healthcare reform. Despite multi-faceted aggressive public invitational postings no community members attended “town hall” style meetings. Further verbal invitations to local churches resulted in five parishioners who perceived most to least significant healthcare issues as being; 1)unavailable/inadequate health insurance, 2)inadequate access to providers, 3)lack of transportation options to an urban center and 4)treatment plans unrealistic in a rural setting. Their expectations included reform to be driven at the federal rather than state level and that such reform include adequate funding. Overall, the failure to generate adequate community participation in this study must be considered in all future efforts to understand healthcare in rural Oregon.

Hormone Replace Therapy for Menopause Symptoms: Creation of a Patient Guide to the Risks, Benefits, and Alternatives
Date of project: 5/1/2006

Hormone Replacement therapy (HRT) for the relief of menopause symptoms has been available to women for more than a century. For the majority of this time the use of HRT has been steadily gaining popularity despite warning signs of potential risks. Results in 2002 from the Women's Health Initiative (WHI), however, dramatically decreased the use of HRT by demonstrating small but significant increases in cardiovascular and cancer risk with HRT. The latest report of HRT and breast cancer risk, published within the last month, has renewed the barrage of media coverage and concern over HRT. Women today who are tyring to decide how to deal with menopause have the challenging task of interpreting a very complex set of data in an arena where there are potentially misinformed sources. The purpose of this project was to deliver a patient education handout that succinctly and accurately summarizes the risks, benefits, and alternatives to HRT.

Surveying the diabetic patients at OHSU Scappoose Family Health Clinic: general characterization of the diabetic cohort and their interest in diabetes educational sessions.
Date of project: 3/20/2006

Lying within the St. Helens service area, Scappoose is a town with a population of 5,480 where diabetes is the 6th leading cause of death by disease5. With its impending expansion of both location and medical personnel, the OHSU Scappoose Family Health clinic is poised “to expand the scope of services we provide [and] to dedicate more resources to patient education programs,” states Dr. B. Rugge, the Scappoose Medical Director. Among the patient education programs under development are diabetes education sessions in small groups. This project assists in targeting diabetes education sessions for adult patients of the Scappoose clinic. By creating and disseminating a survey to incoming diabetic patients at Scappoose during a 2.5 week period, the intention of this project was to better characterize the diabetic population and their concerns about their disease and its complications. 28 completed surveys yielded a 14% representation of the estimated total diabetic cohort. Generally, the results of the survey portrayed a population with the average age of 59 and average duration of diagnosis at 11 years. While 86% whom monitor blood glucose levels, the majority of them (32%) had cbg between 126-150. 64% of those surveyed were interested in attending education sessions. Finally, the top three most interesting diabetes related topics were nutrition, blindness and weight loss. Further specifics are found in the report below. Future considerations would include continuing the survey such that the majority of cohort will have an opportunity to complete the survey, and discovering deterrents to attendance in order to maximize participation.

Food For Your Heart: Socioeconomic status and the prevalence of chronic medical conditions
Date of project: 2/13/2006

Diet and exercise are lifestyle components that have long been known as a means to non-pharmacologically manage chronic medical illnesses such as hypertension, diabetes mellitus and hyperlipidemia. However, there appears to be significant knowledge gaps among certain patients. There is a need for succinct and practical nutrition education geared towards a diverse patient population that includes those with limited incomes. This prompted the question regarding the association of socioeconomic status (SES) and the prevalence of chronic medical conditions. A chart review was done on 50 patients at the Scappoose clinic comparing the prevalence of HTN, DM and hyperlipidemia among patients with private insurance compared to patients with lower SES, as measured by participation in Medicaid programs (OHP, OMAP). The scope of this study was quite limited and did not demonstrate an association between SES and these chronic conditions. However, this research question can be better answered if a larger general population was studied and more specific SES parameters such as income data and level of education are used. Based on the information and knowledge gaps identified from patient interviews, an education brochure was created for distribution at the clinic that included dietary recommendations, practical diet tips and money-saving strategies. It will hopefully serve as a useful tool to counsel patients on more optimal diet management of their chronic diseases.

Chronic Pain Group Classes in Scappoose: Value of the Program, Barriers to Participation, and Advice from Oregon’s Pain Management Leaders
Date of project: 1/2/2006

Chronic pain management continues to be a challenging issue for patients and physicians. Multidisciplinary chronic pain management groups have become an important part of pain management for many patients in Oregon. A group of this nature was recently attempted in a Scappoose, Oregon family medicine clinic. The main obstacle to success was poor attendance. This study attempted to identify barriers to attendance and investigate solutions used by experts who have faced and overcome this obstacle within their own programs. The design was interviews with patients of the Scappoose family practice clinic as well as interviews with pain management leaders. Outcomes data was collected, where possible, to assess the potential value of continuing a multidisciplinary chronic pain management group at the clinic.

Obesity Associated Type II Diabetes Mellitus In Scappoose, OR, Adolescents: Awareness May Lead Early Diagnosis and/or Prevention
Date of project: 10/17/2005

As in adults, the numbers of overweight and obese children and adolescents have tripled over the past thirty years. As a result, the incidence of type-II diabetes, conventionally known as “adult onset diabetes”, in childhood has risen 10 fold. Obesity and its related co-morbidities represent a major proportion of family practice office visits. Indeed, during my time in the Scappoose clinic the majority of the adolescents seen were either overweight or obese. The aim of this study was to determine, using provider interviews and information available for the prevalence of obesity at Scappoose High School, OR, if adolescents are at high risk of developing type II diabetes (DMII), and if so, what are the rates of diagnosis and factors which may limit the process. Adolescents of Scappoose, OR, in accordance to national trends, were found to be at risk of developing DMII but have low rates of diagnosis, raising a concern for the awareness of overweight and obese adolescent patients and their parents. Finally, using the information learned from the study a new patient handout was made, aimed at increasing patient/parent awareness of obesity and DMII, to improve prevention, detection, and long-term outcomes.

The effect of the new Medicare Prescription Drug Benefit on the 65 and older population at the OHSU Scappoose Primary Care Center
Date of project: 9/12/2005

A significant number of the OHSU Scappoose Primary Care Center's patients who are 65 and older do not have prescription drug coverage. These patients bear the entire cost of their medications, and many carefully weigh treatment decisions based on cost. In the author's time at the Scappoose Clinic, numerous encounters were noted with patients from this population where prescription cost was a larger consideration in therapy selection than for those who have prescription coverage. This project describes how the clinic's patients will potentially be affected by new Medicare legislation, effective January 1, 2006, that will provide prescription drug coverage for millions of retired Americans.

Health Literacy in Rural and Underserved Populations
Date of project: 8/8/2005

Does offering health information on topics that are in high prevalence in underserved populations and have more negative outcomes in those populations, improve the health of the population, and are those services readily utilized? Health Literacy regarding diagnosis, disease pathology and treatment options are at a low in rural populations. Without an awareness of what disease processes may be occurring in a patient, it becomes more difficult for patients to help themselves, do the things that are within their own capacity to reduce their morbidity, with respect to their disease. Health Literacy is a key component to health care outcomes, and directly relates to compliance of treatment protocols and adherence to prescribed regimens. Without health literacy, it is more difficult for patients to understand the importance of adherence and more likely for adverse effects to result, and decreased efficacy in treatment outcomes. Low health literacy has also been shown to directly impact the overall health of a community and health education has been shown to improve specific outcomes like reduction in unnecessary office visits, poor health resource utilization and medication compliance. A questionnaire was designed to ascertain the general perception of the patient population of health literacy, and was given to patients as they checked in for visits. When a disease process was identified in a patient that was addressed at the conference, the patient was counseled as to the importance of health information and invited to attend BRIDGING THE GAP NORTHWEST 2005, free of charge. Bridging the Gap is a community education forum, bringing information, tools and resources to the community at large, specifically targeting those underserved populations that are at the highest risk for negative health outcomes based on literacy and economic status. Patients were also offered information on their specific condition, and were asked if they understood the information that was provided.

Prevalence of depression and effectiveness of treatment modalities at OHSU Scappoose Clinic
Date of project: 7/4/2005

Depression is a common reason for primary care visits. Many patients suffering from depression incur tremendous emotional, physical and financial hardship making it an important topic to address. Treatment of patients with depression can be difficult because of patient's compliance, high rate of relapse and tendency to become chronic. However, studies have been done showing that a comprehensive approach for treatment of depression is both cost effective and increases patient's sense of well-being. Morever, the purpose of this study is to estimate the prevalence of depression at OHSU Scappoose Clinic and specifically look at types of treatments received, duration of treatment, which methods of treatment worked best and whether patients felt they had access to care. Methods: A survey was drafted that asked specific questions about duration of treatment, types of treatment received, treatments that worked best, age and sex, and access to care. The patients were handed a survey before appointments with nurse practitioner, physician assistant and physicians, and were given time to fill it out. This was done for a week's duration. Results: A total of 53 people were surveyed; 41 females and 12 males. Of those surveyed a total of 25 were depressed; 21 (51%) females and 3 males (33%). No significant difference in average age and duration of therapy was found for males and females. Drugs and combination therapy were used equally as frequent and 6 patients, 2 males and 3 females, said no method of treatment worked for them. Only 2 out of the 25 patients said they felt like they had no access to treatment. Conclusions: A considerable amount of patients at OHSU clinic with depression are not receiving care that works for them. A recommendation to make treatment of depression more comprehensive and conducive to the patient population will increase quality of care received at OHSU Scappoose Clinic.

Mental Health and Addiction services are vital component of our communities.
Date of project: 4/25/2005

Mental health and addiction services are vital components of our communities. In my short time at the OHSU Scappoose Family Practice (SFP) Clinic, the tremendous amount of mental health and addiction issues within the patient population became readily apparent. This project focused on identifying the major mental health and addiction resources within Columbia County, the county which is home to the OHSU SFP Clinic. Additionally, this project attempted to strengthen the ties and communication between those mental health resources and the practitioners at the OHSU SFP Clinic. The data was obtained through interviews with Columbia Community Mental Health (CCMH) and OHSU SFP Clinic staff members. As a result of the interview with the Executive Director of CCMH, a listing of services provided by CCMH was created and distributed to OHSU SFP Clinic staff. In addition, the framework for efficient and effective long-term communication (about patients, resources, etc.) between the two entities was constructed.

Diabetes Education in Scappoose, OR: Assessing diabetic education through the development of a patient questionnaire and educational handout
Date of project: 3/21/2005

Diabetes is a very common disease in the U.S. and is growing in prevalence by the day. It is a major cause of morbidity and mortality and one of every ten healthcare dollars are spent on diabetes and its related complications.1 Since diabetics themselves are the one’s responsible for the prevention of long-term complications, they must be properly educated on the basic etiology of their disease and it’s management. This study attempts to assess the overall education on pertinent facts about diabetes in both the diabetic and non-diabetic population in Scappoose, OR, and then to educate patients on important concepts and common misperceptions of diabetes management. Overall, this study found that diabetics in general were not more knowledgeable about their disease than the non-diabetic population. In fact, the general population seemed to be more knowledgeable about the etiology, prevention and treatment of diabetes and the diabetic population sampled.

Utilization of Eye Care Services by Patients of Scappoose, Oregon
Date of project: 2/7/2005

Blindness and visual impairment currently affects over 3 million Americans and this number is growing. Visual impairment and blindness are easily prevented in many circumstances through timely eye screening and treatment. Rural populations are traditionally limited in availability of specialized care. The aim of this project is to determine patterns of utilization of eye care services in the rural town of Scappoose. To achieve this goal, patients were surveyed during a 2 week period regarding their risk factors, utilization of eye care services, and vision coverage. Seventy-three patients completed the survey. All of the patients were over 18, with a mean age of 46.57 years. Nineteen patients reported having existing eye disease that included age related macular degeneration, glaucoma, and multiple sclerosis. Seventeen patients reported a history of diabetes, 35 % of these patients had not received a comprehensive eye exam in the past 2 years. The most common reasons given for failing to seek eye care were lack of vision insurance and lack of tangible vision problems. Based on the findings of this survey, an informational brochure was produced for patients. This brochure focused on: 1. Highlighting current screening recommendations, 2. Educating patients regarding common eye disorders, and 3. Providing uninsured patients with resources to obtain vision coverage. This brochure was made available to patients in the clinic waiting room. The four primary care providers at Scappoose were also provided with copies of a recent review article tailored to PCP’s that highlights the recommended role of PCP’s in preventing blindness and visual impairment. Informal discussions were held with each provider to highlight the findings from this project and emphasize their role in vision screening.

Successful aging in the elderly population of Scappoose, Oregon: A report on the resources and facilities available to encourage successful aging.
Date of project: 10/18/2004

The elderly population is the fastest growing group of individuals in the United States. It has been shown that avoiding disease and disability, sustaining high functioning, maintaining and establishing social networks, and actively engaging in life all lead to successful aging in the elderly. Many elderly rely on community services to accomplish successful aging, and it has been shown that rural areas tend to have deceased availability of these services and professionals. This research project identifies and reports the resources available to the elderly population of rural Scappoose, OR in order to age successfully. Visits to the local nursing home, assisted living community, and senior citizens’ center were made. Interviews with staff were conducted and tools to promote successful aging in the elderly population were discussed and recorded. The final report reveals that although Scappoose is a rural community, it contains the resources available to promote successful aging in the elderly population.

Addressing A Possible Solution for Specialty Outreach Clinics.
Date of project: 9/13/2004

OHSU Scappoose Family Practice was recently designated a Rural Health Center. While this designation provides adequate primary care reimbursement for Medicaid and Medicare patients, these patients still experience delays establishing tertiary care. To address a possible solution to this problem we researched the plausibility of specialty outreach clinics. We reviewed 1,000 referrals from the OHSU Scappoose Rural Health Center in 1999 to identify potential specialties with enough patient demand to warrant regular scheduled visits to Scappoose Family Practice Clinic. We also identified which specialties are limited to location by technology, and finally we asked the question if specialties did come to the Scappoose clinic on a regular schedule, would this expedite Medicaid and Medicare patient access to tertiary care. Our findings identified five tertiary specialties that have met these preliminary criteria; Orthopedics, Cardiology, Otolaryngology, Rheumatology, and Dermatology.

Analysis of drug sample use at OHSU Scappoose Family Practice Clinic
Date of project: 8/9/2004

Prescription drug costs are a growing concern for many patients seeking medical care in the United States today. One recent study predicts that drug expenditure growth should continue to outpace the growth in overall health care expenditures and the growth in the U.S. economy. Currently many physicians use free drug samples provided by the pharmaceutical companies to provide medication to their patients. This study attempted to analyze the use and opinions of drug sample resources from three practitioners in a rural OHSU primary care clinic in Scappoose, Oregon. The design was to randomly select 101 instances in which drug samples were given out to patients and analyze as to which physician prescribed the sample, total costs saved for the patient versus local pharmacy costs, and compare with the insurance status of the patient. In addition the three practitioners from the clinic were independently interviewed concerning their views of drug samples to be compared with the actual free sample prescribing habits. The overall objective of this project is to determine if there is any pattern to the prescribing of free drug samples from the clinic and to investigate alternatives available for patients who are not able to afford their prescription drug costs.

Investigate the Use of Unconventional Therapy in Scappoose and Portland
Date of project: 7/5/2004

Unconventional therapy has become popular in the United States. However, the role of cultural beliefs and population size in unconventional medicine use is not known. This study examines the prevalence of and the reasons that underlie unconventional medicine use in two culturally distinct populations in Oregon: the predominately Caucasian population of Scappoose and the Chinese American community of Portland. A survey was designed and was conducted at the Scappoose and Portland health service centers. Among the 14 Caucasian subjects interviewed in Scappoose, 57% reported using unconventional medicine at least once in their life. All of the 16 Chinese American subjects interviewed in Portland have used unconventional medicine. Whether in Scappoose or Portland, the respondents who had tried unconventional medicine used it for chronic medical conditions such as pain and allergies and consulted medical doctors for serious medical conditions including hypertension and renal failure. Furthermore, only 25% of the Portland respondents who used unconventional therapy informed their medical doctors compared to 75% in Scappoose. These results show that over half of the subjects in Scappoose and Portland have used unconventional medicine. However, the subjects in Scappoose are more likely to communicate their use to their medical doctors than do the subjects in Portland. This pattern of use elucidates the phenomenal prevalence of unconventional therapy and suggests that medical doctors should specifically inquire about the use of unconventional therapy when treating patients with different cultural beliefs.

The effects of Chronic psychological stress
Date of project: 5/10/2004

The relationship between psychological stress and overall general health has been well documented in many studies. Chronic psychological stress can elicit negative health effects on numerous organ systems including the immune, gastroenteral, and nervous systems. The hope for this study, via questionnaire, was to examine the prevalence of stress in a small community primary care clinic, the perception of stress and its affect on general health, how often measures are taken by patients in order to decrease chronic stress, and to identify examples of major stressors that affect the community. Furthermore, it was hoped that this study would shed insight to what degree a primary care physician can identify stress and its symptoms as well provide information in stress lowering activity. I found that 31% of the respondents indicated mild to moderate stress and 17% of patients had significant stress. 23% of respondents had severe stress levels. 28% of patients felt that stress had little or no effect on general health. Furthermore, 29% of patients indicated they never take steps to reduce stress. Examples of stressors that were listed in the survey varied in sources. These data suggest stress is substantially present in this rural community. A need to address the health concerns that may be associated with increased levels of stress and careful inquiry by primary care physicians into potential stress would likely benefit the management of patient health issues in a rural community. Identifying and addressing stress related symptoms would likely yield many benefits, i.e. productivity at the work place, increased coping strategies, etc.

Attitudes and Behaviors Regarding Nutrition and Exercise At Scappoose High School
Date of project: 3/29/2004

The rates of obesity have been steadily increasing in rural and urban communities across the United States in recent years. Obesity rates among children and adolescents are growing even more rapidly than those seen for adults. There are many factors associated with the development of obesity; genetics, diet, physical activity and mental health to name a few. In an effort to address these issues, the USDA developed the Dietary Guidelines For Americans in 2002. By directing the implementation of the Dietary Guidelines For Americans towards the youth in America, we may be able to more effectively ensure the development and maintenance of healthy lifestyles. In order to better understand the health attitudes, beliefs and habits of adolescents in Scappoose, Oregon a survey was developed and conducted at Scappoose High School that addressed these issues.

Physical Activity and Youth in Jefferson County: The role of the healthcare provider
Date of project: 1/5/2004

Physical inactivity among all ages is a growing health problem in the United States. Combined with poor nutrition, physical inactivity is second to tobacco-use as a preventable cause of death in Oregon and US. Physical inactivity is a relative risk for coronary heart disease, hypertension, diabetes, strokes, obesity, osteoporosis, depression and anxiety. The prevalence of physical inactivity among youth is high. The “2002-2003 Oregon Healthy Teens Survey” showed that about 66% of eighth graders and 70% of eleventh graders participated in moderate activity less than 5 days per week. This is less than the minimum physical activity recommendations. From the same survey, in Jefferson County about 19% of eighth and eleventh graders exercised moderately 5 or more days in the past 7 days, thus meeting the minimum physical activity recommendations. Addressing physical inactivity in youth is multi-factorial including plan implications at the individual, family, healthcare, school, and community level. The objectives of the 2003 Healthy Active Oregon: The Statewide Physical Activity Plan targets each these various levels. To combine the objectives of the state initiative and needs of the medical clinic in which I worked in Jefferson County, I addressed the following question, “How can a Jefferson County healthcare provider help promote physical activity among youth?” The methods used included literature searches for recommendations for clinical counseling on physical activity, a questionnaire to assess the clinic’s current protocols, and current patients thoughts and questions regarding physical activity, and finally an assessment of what is offered in the community. The final products included an interactive-information questionnaire for patients intended to help healthcare providers assess patients’ physical activity levels, assess barriers and provide patients and their parents the health benefits of physical activity. Also, a list of community resources and additional clinical practice suggestions were made. Suggestions included regular BMI measurements and regular assessment of patients’ physical activity.

Pediatric Asthma Screening in Scappoose, Oregon
Date of project: 11/10/2003

Asthma affects 15 million Americans and 4.8 million children in the United States . In Oregon, 8.2 % of adults and 7.5 % of children are asthmatic, a total of 275,000 Oregonians . Discussion with my preceptor revealed a lack of data regarding the prevalence of asthma in Columbia County and specifically the rural area around Scappoose, Oregon. This paper explores the development of a rural clinic-based pediatric asthma screening program by 1) considering the objectives for a rural screening protocol; 2) evaluating three questionnaires designed for national- and school-based asthma monitoring for their use in a clinic-based program to meet these objectives; and 3) conceptualizing a pilot study to administer this screening tool in Scappoose. The top priorities for this screening program were to detect new asthmatics as young as possible with an inexpensive, time efficient, and simple screening tool that is easily understood by all age groups. The Brief Pediatric Asthma Screen (BPAS) was best suited to achieve these objectives, as it has only five questions with a sensitivity of 75 % and a specificity of 81.2 %. A pilot study is recommended in which this questionnaire would be administered to all children visiting the clinic for one year to screen for known and unknown asthma sufferers. After the first three months of the pilot study, the questionnaire should be assessed for effectiveness in satisfying the objectives of the asthma screening tool. A permanent rural clinic-based pediatric asthma screening program could be established after this pilot year, such that the questionnaire could be administered to all children as part of the review of systems and in well child exams. This asthma screening program would be viable in the rural setting of Scappoose, Oregon in Columbia County or in any primary practice.

PHYSICAL ACTIVITY AND HEALTH IN SCAPPOOSE, OREGON: Identification of Perceived Barriers to Being Physically Active and Development of a Patient Handout on the Benefits of Regular Exercise
Date of project: 9/29/2003

The prevalence of obesity is increasing and continues to be a national problem. Although the benefits of weight control and physical activity are well documented in the primary prevention of many chronic diseases, most Americans do not participate in regular amounts of physical activity at recommended levels. This study attempted to identify the perceived barriers to being physically active in an OHSU family practice clinic located in the community of Scappoose, Oregon. Development and administration of a patient survey during a one-week period was the primary source of data used to identify the barriers to physical activity. Additional information was collected by direct observation of preceptors counseling patients on the topic of exercise throughout the six-week rotation. The goal was to create a patient handout that could be used during office visits to supplement counseling on the benefits of exercise and expose the common myths limiting participation.

Resource Gathering, Early Planning and Evaluation of Group Visits for the West Salem Clinic in the Early Phases of Implementing the chronic Care Model.
Date of project: 11/10/2003

The management of chronic illness constitutes a formidable challenge to patients, practitioners, and the health care budget. The Chronic Care Model has been developed to address the increasing strain chronic illness is exerting on the health care system. The six pillars of the chronic care model are: Community resources and policies, Health care organization, Self-management Support, Delivery System Design, Decision support, and Clinical Information Systems. The West Salem Clinic is currently in the midst of a national two year Diabetes Collaborative aimed at implementing the chronic care model in the management of patients with Diabetes. In an effort to further progress to a chronic care model I researched and gathered resources on group visits and queried patients with diabetes on the interest in being involved in the group visit format, diabetes knowledge, self-management and health care utilization. I found that 60% of patients were interested in the group visit format, perceived knowledge of diabetes appears to be greater than actual knowledge, self-management appears to vary widely, and for this population utilization of their PCP for most patients occurs at every three months or less, with few patients requiring hospitalization for their diabetes.

A Diet Habits Survey of Scappoose Oregon.
Date of project: 8/18/2003

Problem: Study the diet habits of Scappoose Oregon. Population: Patrons and employees of local businesses. Methods: A diet habits survey was circulated to local business for distribution to employees and customers. General Findings: The population of Scappoose had diet habits similar to the rest of the country with the majority of people eating a diet that was approximately 37% fat. There were however several areas where the population surveyed had better than average values. For example, 41% of female respondents adhered to a 30% diet. Scappoose residents in general made healthy choices with seafood with the majority of female respondents falling in the 25% fat category, and the male respondents in the 30% category. Beverage consumption was likewise better than the national average with the majority of female and male respondendts falling in the 30% fat category.

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