RCHC Community Project Abstracts

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Interest and Barriers to a new Nutrition Curriculum in Grants Pass Elementary Schools
Date of project: 10/12/2009

Obesity and the related health events have become an epidemic throughout America. Health related habits are learned at a young age and reinforced throughout childhood. There are currently multiple movements to introduce more nutrition and health education to schools in an attempt to curb this epidemic. Specifically, in Grants Pass elementary schools a group wants to implement a nutrition and health curriculum however little was known about the status of the health education system and potential barriers. The goal of this project was to assess the interest and potential barriers to implementing the “Be a Fit Kid” nutrition and health curriculum in Grants Pass elementary schools. Interest was strong among the 5 physical education teachers interviewed. Each pointed out potential barriers to consider with implementation of the curriculum. Results of these interviews were used as a foundation for writing a grant to fund the program.

The Decision To Transition: Paper Charts vs. Electronic Medical Records (EMR)
Date of project: 9/7/2009

Choosing to switch from paper charts to electronic medical records (EMR) is a major decision, philosophically and financially, for physicians and clinics. This study attempted to compare and contrast the advantages and disadvantages of paper charts vs. EMR and to identify the attitudes that physicians in Grants Pass, OR have towards these two systems. The methodology for this study was qualitative and an interview approach was utilized. Four physicians were interviewed based upon their time spent using paper charts/EMR and their intention of transitioning to EMR. Physician concerns for transition to EMR included quality of patient care, financial stability, time efficiency and impact on quality of life. Recommendations from physicians currently using EMR were included for health care providers considering the transition from paper charts to EMR.

Health Literacy and Patient Knowledge of their Chronic Illness in a Rural Population with Hypertension
Date of project: 8/3/2009

Health literacy refers to the ability of an individual to obtain, process, and understand health information needed to make informed decisions about managing their health. Limited health literacy is common in the United States and is important because it is related to health knowledge, health behaviors, and health outcomes. In this project, the health literacy of a population of primary care patients with hypertension in Grants Pass, OR was assessed and then patients completed a questionnaire asking basic questions about the risks and management of this disease. The goal was to assess the level of patient knowledge regarding their chronic illness and to see if that correlated with health literacy status. Patients were found to have a good overall understanding of blood pressure goals, risks of untreated hypertension, and strategies to reduce blood pressure. Patients were least likely to understand dietary strategies to reduce blood pressure and only about one-third could correctly list all blood pressure medications they were currently using. Patient education materials regarding dietary management of hypertension were obtained for use in the clinic and several strategies for maximizing patient education were presented to the staff of the clinic. Because of homogeneity in health literacy status in the study population, associations between health literacy and patient knowledge was not possible.

Non-Medical Exemptions to Immunization in Josephine County, OR
Date of project: 6/29/2009

Religious and personal-belief exemptions to mandatory childhood vaccinations are increasing in states across the country with Oregon having the fourth highest overall rate. Within Oregon, Josephine County regularly ranks near the top in terms of annual "religious" exemptions to immunization. Oregon's process for attaining an exemption is easier than in most states. While Oregon does not have a "personal belief" exemption, state law defines "religion" broadly as "any system of beliefs, practices or ethical values." In this study, I looked at rates of religious exemptions within Josephine County as well as factors associated with "vaccine hesitancy". I found that vaccine-hesitant and non-hesitant parents did not differ in terms of engagement in religious or other groups. Vaccine-hesitant parents, however, were significantly more likely to use friends or the internet as sources of vaccine information but significantly less likely to use health-care providers. This student emphasizes the importance of outreach by health-care providers to vaccine-hesitant communities and stresses the importance of crafting firm but constitutional laws mandating childhood vaccines.

Educating the Future
Date of project: 2/9/2009

From a health care perspective, one of the most difficult tasks in a rural setting is recruiting new physicians to the area. Grants Pass has a population around 30,000 with a wide variety of specialists to serve the population. The problem: physicians are aging and there isn't anyone willing to replace them. It has gotten so bad that the general surgeons are threatening to cut weekend call all together. The greatest hope lies in the community's youth who are likely to return to their hometown upon completion of their training. I was invited to Grants Pass High School to teach the students in the advanced medical skills class how I became interested in medicine, what I did to get into medical school and what life in school is like. It was my goal to demonstrate how much fun medicine is, and how they can go about getting into medical school. To show how much fun it is, I used hypothetical trauma scenarios and asked them what to do. The next day, I brought in 12 pigs feet along with suture material and taught them how to suture using sterile techniques. Through this process, I learned how a physician is not solely a healer, but an educator as well. It is a physician's duty to educate the community. I used the classroom to educate students about medicine, and it was clear that more than a couple of interests were sparked.

Health Screening Awareness in Grants Pass
Date of project: 12/29/2008

Preventative health services are central to individual health while maintaining low overall health care costs. While on my rural clerkship in Grants Pass I found that patients of the Grants Pass Clinic were largely unaware of health maintenance screening guidelines. Further, while performing colonoscopies, I noted the age of most patients was higher than I expected. I then accessed the local OHP plan, OHMS, for claims data for colonoscopies amongst 50 year-olds and mammograms amongst 40 year-olds. This demonstrated the poor compliance of the Grants Pass community with recommended health screening, ranging between 7-15% of patients for these services. I addressed this problem by creating an informative pamphlet to be distributed to OHMS members and to be displayed within the Grants Pass clinic. I hope to increase local compliance with health screening by 10% in the next year.

Childhood obesity in a rural setting
Date of project: 10/13/2008

The prevalence of childhood obesity among US children has increased between 2-4 folds in the last 40 years. The state or Oregon has not been an exception from this nationwide epidemic and in fact one in four eighth-graders in Oregon are now overweight or at risk of becoming overweight. Studies have been conducted looking at the causes and origins of this potential disaster. However, few of these studies have been done in a rural setting. An array of environmental and social changes that severely challenge a family’s ability to make healthy choices for their children have contributed to this epidemic, including barriers to safe and accessible physical activity and fresh, nutritious foods, coupled with an increase in sedentary pastimes such as television and computers, known as "screen time", and more frequent use of automotive vehicles rather than walking and biking for transportation. This article is intended as a very preliminary beginning at studying childhood obesity in a rural setting with the ultimate goal of providing additional insight into this problem as well as potential possible solutions.

Access and quality of Hospice services for patients and physicians in Josephine County; continual strives towards quality assurance
Date of project: 9/8/2008

Rural communities in Oregon are facing the aging population of baby boomers. As such the demand for physicians and Hospice services to deal with end of life care is in high demand. Nationally and within Oregon, rural hospices are faced with additional burdens of large square mileage areas of coverage, increased financial burden due to higher overhead costs and less Medicare reimbursement per patient, and late referrals to care with short lengths of stay. Through analysis of a physician survey about hospice experiences and interactions, interviews conducted with Hospice personnel and patients, and local and statewide annual reports for Lovejoy Hospice located in Grants Pass, OR was analyzed for its ability to address the aforementioned issues. It was found that Lovejoy Hospice through several methods such as attention to provider vs. patient locations, extensive annual fundraising, and finally a physician handbook and positive community presence and patient interaction, has addressed these problems and physician concerns with Hospice referrals and transition to care. However, through physician surveys and Hospice personnel interviews, it was identified that the transition to Hospice care could be smoother and that one are of improvement would be initiating earlier hospice planning so a plan was in place before acute patient decline. Therefore, the final product of this project was development of a patient/physician resource handout and pre-enrollment consult form providing physicians with an in-office way to initiate a conversation about end-of-life and hospice care, and brief patient epidemiology and end-of-life desires for Hospice to have on file in order to facilitate a smoother transition to Hospice care.

Preventing Caregiver Burnout in Grants Pass, OR
Date of project: 8/4/2008

At any given point, there are 34 million Americans who provide full or part-time care to aging family members or spouses1. Unfortunately, caregiver stress and burnout continues to be an under-recognized and under-addressed phenomenon, despite its association with increased morbidity and mortality in both caregiver and care-recipient. The goal of this project was to identify resources readily available and easily accessible to caregivers in Grants Pass, Oregon. The design included observation of physician interactions with caregivers and their dependents at WellSpring Family Practice and Three Rivers Community Hospital as well as exploration of local, state, and national support resources for caregivers. Finally, the end-product of this project was a pamphlet outlining essential steps for the caregiver and elucidating the most useful and comprehensive resources available. The pamphlet was made to be distributed in the physician’s office and various other health resource offices (e.g. CareSource, assisted-living homes).

Management of Patients Abusing Opiate-based Analgesics in Grants Pass: Individual Healthcare Provider Practices, Clinic Guidelines, and Resources and Obstacles in Josephine County
Date of project: 6/30/2008

Management of patients abusing prescription opiate-based analgesics is challenging and requires the interplay of many different healthcare providers and community resources. This study identified individual healthcare provider approaches to the management of this population of patients, Grants Pass Clinic policy, and the resources available in and around Josephine County. Information regarding individual healthcare provider practices was obtained via a questionnaire, while resources for and obstacles to the management of this population was gathered through interviews. Healthcare providers generally shared common views and strategies regarding the management of patients abusing prescription narcotics. Discrepancies were found when considering the use of pain contracts and the appropriate time to fire a patient. Grants Pass Clinic had no policy or patient information on the management of patients abusing prescription narcotics aside from the pain contract, so a double-sided handout was created to address the need. Grants Pass has many opportunities for individual drug counseling, less opportunities for group counseling, and nearly no maintenance therapy services (methadone or Suboxone). Possible means to improve access and availability to patients abusing prescription narcotics include increased government funding, reducing healthcare provider prejudice, and increasing the number of healthcare providers trained in Suboxone administration.

Educational Tools to Promote HealthY Patient Behavior
Date of project: 4/28/2008

Diabetes and hyperlipidemia are now well established risk factors for cardiovascular disease that are quite poorly controlled in our country. Each of these medical conditions drain the health and financial reserves of all of our communities. Grants Pass, is an economically challenged community located in Josephine County Oregon. High rates of cardiovascular disease and chronic medical conditions in this city serve to only worsen the already poor socioeconomic state of this city. The Wellspring Family Practice Grants Pass clinic is composed of a high proportion of patients with diabetes and hyperlipidemia. Unfortunately, the patients lack a sophisticated understanding of how these disease processes lead to harm in their lives. Furthermore, many individuals were frustrated with the lack of success of lifestyle intervention and were skeptical that improved diet and exercise would improve outcomes in their community. The results of this study confirmed that increased exercise, improved diet and tight glucose control were all correlated with better health outcomes in this population. The findings appear to support the applicability of well established cardiovascular risk factors in this community and thus provide an additional powerful set of educational tools to promote health patient behavior.

Opportunities For and Barriers Against Watchful Waiting as an Initial Management Strategy of Acute Otitis Media in a Rural Pediatric Practice
Date of project: 3/17/2008

Over-usage of antibiotics has been identified as a source of antibiotic resistance. To combat the emergence of drug resistance many groups have sought to identify diseases in which antibiotics are frequently used where they are needed to bring out resolutions of disease. Acute otitis media (AOM) is one such disease. In fact, AOM is the most common disease for which a child is given antibiotics. A recent statement by the AAP's Subcommittee on the Management of Acute Otitis Media has stated that observation without antibiotics is appropriate initial treatment of a sub-group of patients. A study published in JAMA in 2006 that was conducted in a metropolitan ED confirmed that watchful waiting in the form of "wait-and-see prescribing" (WASP) was not associated with significant differences with regard to subsequent fever, otalgia, or unscheduled ED visits when compared to day-of-visit prescribing. I wanted to see how often patients in the office-based pediatric practice in Grants Pass, Oregon were prescribed antibiotics for AOM when watchful waiting would have been justified by AAP criteria. I chose to do this because I saw more cases of AOM than any other disease during my rotation and noticed that most children received antibiotics as an initial course of therapy. To assess physician prescribing behavior I reviewed the charts of 55 patients seen between Jan 1, 2008 - March 31, 2008 who were diagnosed with acute otitis media. The patients were selected via ICD-9 code for otitis media. 55 patients with MRIPA insurance were seen between Jan 1, 2008 - March 31, 2008 and diagnosed with AOM. Six patients were excluded. Of the remaining 49 patients (provider breakdown: Ayoli = 18, Crispen = 12, Marshak = 14, Burnett = 5), 31 (63%) were eligible for watchful waiting according to the AAP. The remaining 18 (37%) fit criteria for immediate treatment. 46/49 patients were prescribed antibiotics immediately. 3/49 were offered antibiotics under WASP. All 3 WASP patients were eligible according to the AAP guidelines. Physicians were interview about barriers to WASP. Most common responses were financial burden of additional visits and fear of compromise to customer service element of modern practice. In the end a handout was created to facilitate the WASP discussion.

Prenatal care resources available for low-income women in Grants Pass, OR
Date of project: 12/31/2007

Adequate prenatal care is important for both maternal health and pregnancy outcomes. There are various social and behavioral risk factors for inadequate prenatal care, including low-income status. Therefore, it is imperative that resources are available for low-income pregnant women, in terms of access to prenatal care and patient education. According to census data, in 2000, 13.3% of the Grants Pass, OR population was below the federal poverty level ($17,170 for a family of 3 in 2007), and 37.4% were below 200% of the federal poverty level. This is in comparison to 11.6% and 29.6%, respectively, for Oregon as a whole. This study examines various prenatal care and education services available to low-income women in the Grants Pass area. Phone interviews were conducted with a coordinator at the Pregnancy Care Center, a county public health nurse, and a maternity case management nurse. In-person interviews were conducted with a member service manager at Mid-Rogue Independent Physician Association (MRIPA/OHP), and several patients. Printed materials available to patients were also obtained from Mid-Rogue IPA, a local county health office, and the Pregnancy Care Center. The findings suggest that a variety of prenatal care resources are available for low-income women in Grants Pass, but several barriers exist, including limited staff and funding for programs. Further examination of ways to optimize prenatal care and education at low cost, as well as potential initiatives to increase funding, would be beneficial.

Improving information and support services available for parents of autistic children
Date of project: 9/10/2007

The prevalence of autism in the United States has increased over the last ten years. Parents of an autistic child face many challenges, as their child often has additional health care needs such as physical, occupational, and speech therapy, and requires specialized educational programs. Parental support and education about autism are important aspects of caring for an autistic child, as a child’s home environment can greatly improve his/her overall functioning. The goal of this study was to evaluate what kind of information and resources parents of autistic children at Siskiyou Pediatrics in Grants Pass, Oregon were given. Interviews with pediatricians and parents revealed the need for a concise patient brochure with information on local and regional autistic services. Through an internet search, different agencies providing parental workshops and support groups in the southern Oregon region were located. As a result, a patient brochure was created which the pediatricians at Siskiyou Pediatrics can give to parents of autistic children. Hopefully, this information will be beneficial to parents as they will be equipped with the tools they need to understand, manage, and improve their child’s condition

Snow Safety: Preventing the most common types of injury at Mt. Ashland
Date of project: 8/6/2007

Mt. Ashland is a small ski resort in Southern Oregon. Despite it's small size Mt. Ashland boasts it's share of difficult runs with approximately 50% of the runs receiving an "advanced" rating. It is primarily a "local" mountain with over 90% of user visits coming from the surrounding area. All of these factors combine to create a scenario where injuries are likely to occur, but where there is a concentrated, local population that is likely to benefit from education on injury prevention strategies. For my rural project, I contacted the ski patrol and administration of Mt. Ashland ski area. We discussed the most common causes of injury at Mt. Ashland, which correlated well with causes of injury nationwide. These causes of injury included knee injuries, head injuries, shoulder injuries and thumb injuries in skiers and ankle injuries, wrist injuries, head injuries and shoulder injuries in snowboarders. I then researched prevention strategies for avoiding these types of injuries and produced an informative poster. I then submitted the poster to the Mt. Ashland administration in order that they might use it to inform the public in hopes of reducing the number and severity of injuries at Mt. Ashland.

The state of teen pregnancy in Josephine County
Date of project: 4/30/2007

Nationwide Oregon ranked 16th (50th = highest) for teen pregnancy rates in 2004. The trend is an overall decrease in the number of teen pregnancies across the nation, the state, and the counties. Despite favorable statistics, further assessment of resources available in Josephine County are concerning for inadequate sexuality education, lack of contraceptive access, and few services for young parents. Teen pregnancy has considerable social, economic, and personal costs, and resources need to be re-allocated in order to continue a downward trend in teen pregnancy, rather than a stasis or increase.

The perioperative evaluation of the diabetic patient in Grants Pass, OR: A patient guide for long-term disease management
Date of project: 3/19/2007

Diabetic patients remain amongst the more vulnerable and complicated surgical candidates. Experts agree that the most effective measure taken to minimize peri-operative morbidity is maintaining long-term glycemic control. During a family medicine clerkship in Grants Pass, Oregon, it was noted that both patients and providers felt that improving patient awareness regarding diabetes management is key in achieving the optimal glycemic control. Given the complexity and scarcity of local diabetes educational resources, a summarized guideline was designed in the form of a patient hand-out to enhance peri-operative cooperation amongst patients and their various health care providers. Based on the request of local family doctors, a portion of this hand-out was dedicated to dietary instructions and risk factor modifications that can serve as a supplement to in-office discussions between the physician and the patient.

Continuity of Care and Medical Information of Children in Foster Care
Date of project: 9/11/2006

In 2005, more than 6000 children entered foster care in Oregon and the population is growing. Foster children are at particular risk for adverse health outcomes and these risks are exacerbated by a common failure to obtain, document, and transmit medical information to case workers, foster parents, and health and social service providers. This jeopardizes the children's health, undermines attempts to provide them with services, and risks unnecessary resource allocation and financial burden for the children's families, foster families, state and healthcare system. The purpose of this project, which was conducted in collaboration with the Josephine County branch of the Department of Human Services (DHS) Child Welfare Office and Siskiyou Pediatric Clinic, LLP of Grants Pass, Oregon, was to address this problem by creating a medical data collection tool and protocol to facilitate the recording and transmission of medical information of children in foster care. The project consists of four phases: information gathering; design and development; implementation; and evaluation, modification, and expansion. At the time of this report, the project is completing its second phase and will soon be implementing the pilot instrument and protocol. To date, the response from the pediatricians and social service providers involved in the project has been very positive.

Mental Health Issues in Josephine County: Facilitating the Transition from the PCP's Office to Community Mental Health Services
Date of project: 8/7/2006

Psychiatric illness is a major medical issue in the community at large and is too often under-treated. The problem of inadequate identification and treatment appears to be even more severe in rural areas. This study explores issues that render provision of mental health services in rural areas problematic and discusses a particular mental health issue, namely depression, in some detail. This issue is considered in the context of Josephine County with special emphasis on the Grants Pass area. A patient pamphlet was designed with the purpose of educating patients regarding the illness, screening patients for the illness, and informing patients of their options in the event that they did in fact feel depressed.

Early Identification of Post-operative Needs of Hip Fracture Patients in Grants Pass, Oregon
Date of project: 7/3/2006

Hip fractures are common and debilitating injuries that predominantly affect older people. They results in significant morbidity for those who suffer from them and place a considerable burden on the health care system. Three Rivers Community Hospital in Grants Pass, Oregon has initiated a comprehensive program directed at senior citizens in its service area that includes fall prevention, osteoporosis care and hip fracture treatment. An important part of treatment is meeting the post-operative needs of patients through timely and appropriate discharge planning. This student examined records of 91 patients treated at Three Rivers Hospital for hip fractures in 2005 to determine what factors at presentation predict length of hospital stay and whether patients are transferred to their homes or to skilled nursing facilities. Available charts were reviewed of the 93 hip fracture reductions performed at Three Rivers Hospital in 2005. Analyses demonstrated no relationship between the number of comorbidities listed for a patient and her length of stay in the hospital. 85% of patients required post-operative transfer to skilled nursing facilities. The mean age of those patients was 8 years older than the mean age of patients who were discharged to their homes. Also, patients bound for nursing facilities had an average of 2.2 greater comorbidities on admission than patiens who were sent home. Patients living at home with a spouse before injury were the most likely to be able to return home after surgery. Further investigation is needed to assess potential relationships between the types of fractures, types of procedures, and discharge plans. The ability to prepare for post-operative placement early in the course of treatment would facilitate the recovery process and provide for the optimally efficient utilization of hospital resources in Grants Pass.

Medication Compliance in the Elderly Population of Grants Pass
Date of project: 5/1/2006

Medication non-compliance is an important issue facing the elderly population because they have the highest prevalence of chronic disease and the largest consumption of medications. Non-compliance is associated with large increases in morbidity, mortality, hospital admissions, and cost to the community and health care system. This study was designed to evaluate and improve the factors contributing to medication non-compliance in the growing elderly population of an internal medicine clinic in Grants Pass, Oregon. Factors were identified using the following methods: extensive review of the literature on medication compliance, surveys of the patients regarding contributing factors, interview with the physician, and identification of resources currently available in the community. Based on the results, a patient handout with a medication log was constructed in order to address these problems and implemented in the internal medicine clinic. Both patients and physicians had a positive response to the handout, however there was not sufficient time to evaluate the effects of the handout/medication log on compliance. Additionally, further work beyond patient education is necessary in order to have the greatest impact on compliance including education of health care professionals and changes within the health care system.

ASSET: Acute ST Segment Elevation Taskforce Awareness in Grants Pass, Oregon
Date of project: 3/20/2006

Heart disease is the number one cause of mortality in Grants Pass, Oregon. Through recent studies, it is clear that Percutaneous Coronary Intervention is the best treatment option for a patient suffering from a myocardial infarction. The Acute ST Segment Elevation Taskforce, serving Grants Pass, was implemented in order to reduce infarct time between recognition of symptoms and therapy. Unfortunately, many patients are not aware of this program and are transporting themselves to the local hospital, one without treatment capabilities. With community education and awareness through direct patient contact, local newspaper articles, posters, and other media, patients were educated about the program. Such education resulted in an increased willingness to use the program and decrease morbidity and mortality.

MRSA infections in rural areas
Date of project: 2/13/2006

Community acquired MRSA is a growing problem in Grants Pass. I set out to get an idea what kind of problem this represented in the area. After looking at the disease from a variety of perspectives, I began to realize that the prevalence of the disease may outgrow the medical community’s ability to respond. I began this project in the hospital. I attended the quarterly infectious disease board meeting. Here I was introduced to a current assessment of the problem of both nosocomial MRSA and community-acquired MRSA in Josephine County. Dr. Daniel Selinger, the infectious disease specialist at the hospital, and Marjorie Underwood, the infection control nurse, were both helpful in answering my questions about hospital infection control policy. As it turned out, beginning in February, Three Rivers Hospital was changing some of their hospital protocol with regards to control of MRSA. This new policy was a divergence from the sister hospital, Rogue Valley Medical Center, in Medford and highlighted an ongoing national debate over proper infection control policy. I also spoke with Dr. Ruth Rabinovitch who is Dr. Selinger’s counterpart at Rogue Valley and is an adherent to the other policy approach. In the outpatient setting, I performed a chart review of any patient who during the last three years had a skin or soft tissue infection associated with MRSA. I examined twenty two charts, eleven of which contained a history of MRSA infection. Specifically I was looking for any of the risk factors associated with either a nosocomial MRSA infection or a community acquired MRSA infection. For the third component of my project, I visited both the county jails. At the Josephine County, I had a chance to interview the staff nurses who take care of the inmates. I wanted to get an idea of how they perceived the problem and what was their approach to treating infections that may be MRSA positive. I also had a chance to participate in a clinic for the inmates at the Jackson County jail. Here I had a chance to see some cases of skin and soft tissue infections and observe the Public Health Officer, Dr. Jim Shames, assess and treat these patients Although I did not come away from this experience with any solid answers about MRSA in a small community, it was heartening to see so many providers, in the hospital, in the clinic and in the community, that were working diligently to slow the growth of this inevitable phenomena.

Increasing vaccination rates in the elderly
Date of project: 1/2/2006

Prevention of disease is one of the most important roles of the primary care physician. Vaccination is a simple and effective way to increase the health and decrease the healthcare spending in all communities across the nation. The elderly are particularly vulnerable to infectious disease and yet vaccination rates are low among the large elderly population of Josephine County. Over one in five people in Josephine County are over the age of 65. Nearly ten thousand over the age of 65 are 5 times increased risk of invasive pneumococcal disease due to inadequate pneumococcal vaccination. Over ten thousand elderly are at increased risk of hospitalization and death due to low influenza vaccination rates. The influenza vaccination itself is effective in decreasing hospitalization due to respiratory illness by 76% and death due to respiratory illness by 79%. In addition, each flu vaccine given saves an average of $47 in health care spending by those who receive it. This project’s ultimate goals are: to understand the vaccination rate and programs already in place within the county health department to increase vaccination rates in the elderly; to increase the vaccination rates in the elderly in Josephine County by supplying primary care physicians with a simple, concise information sheet for patients to help them understand the risks and benefits vaccination with the Influenza and Pneumococcal vaccines. This information was gathered from large cohort studies or RCT’s in the primary literature and these references were supplied along with the information sheet to primary care physicians in the area who wished to use them. Follow up research could be done in the peak influenza vaccination season to determine the effectiveness of the County Health Dept. planned interventions outlined in this project.

Parental Concerns Regarding Vaccinations in Grants Pass
Date of project: 10/17/2005

Childhood immunizations are an important step in decreasing the amount of disease in communities. This study attempted to ascertain why some parents whose children receive care at Siskiyou Pediatrics in Grants Pass, Oregon choose not to immunize their children and to identify some of the concerns parents have regarding vaccines. A questionnaire and cover letter was developed to gather information from parents. After collecting the responses, it is clear that parents take the decision on whether or not to immunize their children very seriously and that misinformation about vaccines contribute a lot to parent's concerns about immunizations. These false beliefs persist despite all the pamphlets available to parents in the exam room. After speaking with a few parents about their worries, it became clear that the parents felt better about the immunizations after their concerns were heard and addressed.

Management of Chronic Back Pain: Evaluation of the Efficacy of Spinal Surgery
Date of project: 8/8/2005

Less than 10% of individuals who experience back pain will develop a chronic back pain syndrome. Of these patients, a fraction will fail all conservative therapies and seek relief through one or more spinal surgeries. There is much controversy regarding the effectiveness of surgery compared to an intense rehabilitation program. During a meeting of the Independent Physician's Association (IPA) of Josephine County, this issue was discussed in relationship to disbursement of state and federal funds to provide coverage for a procedure that has not been shown to have steadfast value in the management of patients with chronic back pain. This project was devised with the ultimate goal of examining the pre- and post-operative functionality and use of prescribed medications of patients undergoing back surgery. A small sample of patients who have undergone one or more back surgeries were selected from a family practice clinic in Grants Pass, Oregon. Their charts were reviewed and documented information on functionality, number of office visits relating to pain, and medication usage were extrapolated. The results of this project were inconclusive as insufficient information was present in the patients charts. Future research could evaluate efficacy of surgical treatment by utilizing IPA databases, contacting and surveying patients, and running analyses on changes in medication utilization.

Substance Dependence In Josephine County
Date of project: 7/4/2005

Background: The abuse of substances including tobacco, alcohol, and elicit drugs impact the wellbeing of the individual and drains the financial and social strength of the community. I-5 is a major corridor for drug traffic and smugglings. In Oregon, the nest of this problem appears to be small rural communities along this mega-highway such as those found within Josephine County, including but not restricted to Grants Pass, the site of my rural rotation. In Josephine County, 33% of adults were smokers in 2001; Alcohol was the eighth top cause of death in 2002; In 2004, the Josephine County Sheriffs office seized 25 methamphetamine labs, 7,891 marijuana plants, and 198,718 grams of drugs with a street value of $19,479,868. This study examines the availability, accessibility, and effectiveness of medical treatment and rehabilitation services for individuals with substance dependence within Josephine County. Method: Research was conducted through the internet and yellow pages, followed by questionnaires and interviews with local Josephine county healthcare providers, a hospital social worker, an addiction counselor, and representatives of local rehabilitation programs involved in the care of individuals with substance dependence disorders. Results: Findings indicate a lack of funding, dwindling services and resources, and defective communication and referral protocols are among the sources of problems with access and quality of care for substance dependent individuals. Conclusion: I propose that protocol for referral and communication between the primary care community and the mental health/substance abuse treatment community be reevaluated by a committee of representatives from all involved parties and that new protocol be established and made clear to all members of these parties for the improvement of access and quality of care to patients. Meanwhile, a chart that lists local resources and summarizes some referral protocol was developed and distributed locally to several local primary care providers.

ASSET: An Effort to Improve Outcomes for Acute MI Patients in Rural Southwestern Oregon and Northern California
Date of project: 4/25/2005

With the increasing numbers of patients with coronary artery disease in this country spanning from metropolitan cities to rural communities, there is a growing population of patients at risk for acute myocardial infarction. Successful treatment of acute myocardial infarctions requires adequate and prompt identification and transfer to a facility for definitive treatment. The most effective treatment for ST elevated myocardial infarctions (STEMI) is percutaneous coronary intervention (PCI). Rapid PCI is the treatment of choice to minimize morbidity and mortality from STEMI. Unfortunately, time is heart muscle in the event of a heart attack. In rural communities, local hospital evaluation, transport to the nearest cath lab many miles away, and activation of the cardiac care team leads to a delay of 2 hours or more. The ASSET program developed by Dr. Brian Gross in Medford, Or has attempted to minimize the time delays and get cardiac patients in rural communities to definitive catheter treatment in a timely fashion. The program involves local rural community hospitals and their ambulance services as well as a group of on call interventional cardiologists in Medford to serve a nearly 50 mile radius around the Medford area. The protocol allows for first responders to identify STEMI patients in the field and bypass the nearest local hospital to transport the patient to a pre-alerted cardiac intervention team in Medford. The outcome was a decrease in the morbidity and mortality associated with time delays accrued in the rural setting and to make rural Oregon the “safest place to have a heart attack”.

Single Parent Support Group
Date of project: 3/21/2005

The United States is home to approximately fifteen and a half million single parents.1 Studies have demonstrated the risk of onset of depression among single parents is double that of their married counterparts with social and financial support being significant variables influencing depression2,3 The large number of mental health problems seen in primary care clinics makes this issue a commonly addressed complaint. This study attempted to identify single parent patients suffering from depression and evaluate the effectiveness of a social support group in helping to reverse their depressive state. The design was recognition of depression in single parent patients and then introduction of these patients into a group of other single parents within their community allowing social interactions and self-determined topics of discussion. While identifying single parents suffering from depression or those who simply had interest in participating in the support group was easily done, there was no existing support group in the community for single parents. Therefore the final product of this project was development of bimonthly support group for single parents with the goal to eventually incorporate family activities, a baby sitting cooperation and educational activities. Parents were encouraged to bring their children with the secondary goal of providing a safe environment for the children to interact with others in similar family structures. The group met for two hours twice during the five week rotation. In addition to self-directed discussion the group was provided with literature addressing various topics regarding parenting techniques, community resources, and self-help motivational information. The effectiveness of the social support group was evaluated by an anonymous survey provided after the second meeting.

Neonatal Mortality in Josephine County: Current and Historical Perspectives
Date of project: 2/7/2005

The problem of neonatal mortality and its associated risk factors in Josephine County, Oregon was examined in 1997 by OHSU Masters student and Public Health Nurse Virginia Adams. Her work demonstrated a community whose newborn babies suffered a 33% increased relative risk of neonatal mortality (death within the first 28 days of postnatal life) compared to babies born elsewhere in the state. The objective of this investigation is to compare the most current statistics regarding neonatal mortality to this historical data to identify areas of improvement and continued struggle within the community of Josephine County. Methods employed in this investigation include critical examination of health statistics and a series of interviews conducted by myself with care providers in Josephine County. To the credit of the community, this investigation found many admirable gains made by dedicated providers. Since the publication of Adams' study, neonatal mortality rates have in Josephine County have decreased significantly (from 8.6 to 5.0/1,000 live births), rates of inadequate prenatal care have dropped from 10.1% to 3.6% (well below OR state averages), and numerous other risk factors for poor neonatal outcomes have been decreased. However, despite these gains, several substantial problems exist in Josephine County which pose potential threats to newborns. Perhaps most notably is the problem of illicit drug use during pregnancy, for which Josephine County maintains the highest rate of all counties in Oregon. Other persistent risk factors for neonatal mortality identified by care providers include recent reductions in public funds which have forced clinic closures and ended subsidized housing programs for pregnant women.

A Diabetic Management Flowsheet for patients of Primary Care Physicians Based Upon Current Guidelines.
Date of project: 1/3/2005

The management of the patient with Diabetes in the primary care environment is both a great challenge as well as a great opportunity for substantial prevention of serious sequella associated with poor control of blood glucose both over the short and long term. Many guidelines are recommended, and the burden of meeting these care guidelines falls squarely upon the primary care physician, and in rural communities the family physician is the first line of management, with more complicated cases being managed by an endocrinologist where geographically possible. The population targeted in this project is limited to those with diabetes being seen by Dr. Dan Gleffe, a family physician in Grants Pass for the past 18 years, but is intended to be usable by any primary care physician desiring to closely and systematically monitor recommended health guidelines of diabetics. Current management guidelines and recommendations were obtained and compiled onto a one-page table format in the attempt to standardize diabetic management and assist the primary care physician in attaining recommended goals.

Perceived Availability of Physicians To Patients in the Clinical Setting
Date of project: 10/18/2004

Access to medical care is often the main barrier to health in a rural community. While access can take on many different meanings for a community, I chose to focus on the perceived availability of physicians to patients in the clinical setting. I observed an independent Internal Medicine practice of 4 physicians and 2 nurse practitioners serving roughly 12,000 patients in a rural area. Over a five-week period, I observed office staff and physician perceptions that patients have many unrealistic expectations for the logistic aspects of their health care. I listened to patients’ questions and expectations regarding their care by the facility. Unnecessary phone calls and incomplete follow-up were two main complaints by office staff, while not being able to talk to a person on the phone and high cost of medications were consistent problems noted by patients. This informal research resulted in the formation of an educational handout to patients to improve their expectations of the logistics of their medical care. By improving patient knowledge of appropriate interactions with the office staff, it is hoped that there will be a decrease in unnecessary phone call volume, to ultimately improve access to the clinic for urgent concerns.

Pedometers as Motivational Tools to Increase Physical Activity in Philomath Oregon
Date of project: 9/13/2004

Physical inactivity has been identified as one of the top contributors to obesity. Combined with poor nutrition, it is the second highest preventable cause of mortality. In preliminary studies, pedometers have been shown to be a potential motivational tool to increase physical activity. The purpose of this study is to investigate the effects of a 7-day, pedometer-based lifestyle physical activity intervention. Participants were 10 patients from Philomath Family Clinic who volunteered to participate in the study. Participants’ perceived physical activity and actual physical activity was measured through questionnaires and by wearing a pedometer while doing typical activities. Questionnaires also examined patients’ motivation, environmental barriers, and knowledge of exercise. After completion of the 7-day trial, participants are asked to reflect on their activity level and their experience with the pedometer. Results indicate participants averaged 14,754 steps per day. Preliminary, findings from this study demonstrate that pedometers encourage most participants to want to increase their activity level.

Newborn Discharge Packet for Siskiyou Pediatric Clinic Patients
Date of project: 9/13/2004

This project was designed to provide a brochure of important information for parents of newborns at the Three Rivers Community Hospital in Grants Pass, OR. Multiple resources exist to provide support and advice to parents of newborn infants. However, most of these require the use of internet access or the financial ability to purchase parenting books. Pediatricians supply many free handouts that parents can collect, but many of the parents I talked with indicated a desire for a quick reference source that gave them bulleted points outlining key information and guiding them in when to access their pediatrician. Interviews were conducted with new parents, nurses in the Family Birth Center and the pediatricians at Siskiyou Pediatric Clinic in Grants Pass, OR in an attempt to determine the most important topics to include and what the best format to present this information. A brochure format was believed to provide the best presentation of information for this community. Further data collection determined five main areas for the newborn brochure, including newborn safety, immunizations, well-child checks, local contact numbers and guidance on when a new parent should call the pediatrician. The product of this project is a brochure entitled "Newborn Information That Every Parent Needs to Get Started" that will be given to every parent in the Family Birth Center before discharge from the hospital.

Lessons Learned from Initial Clerkship- Experience in a New Community
Date of project: 7/5/2004

As the first 3rd year clerk in Grants Pass, OR, I set out to assess the expectations of the medical community regarding the rural training of OHSU medical students as well as to inform the preceptors, the hospital administration and additional medical staff regarding the goals and objectives of the rural clerkship. To achieve these goals, I conducted a focus group study that had the following specific objectives: To determine the relevance of the OHSU Rural Community Health Clerkship goals and objectives in relation to the expectations of the rural clerkship preceptors. To assess the opportunities available for clerks throughout the medical community. To assess the level of interest in increasing OHSU's footprint in Grants Pass.

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