RCHC Community Project Abstracts

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Medical Marijuana in a Small Town: A Growing Issue
Date of project: 9/7/2009

Several states have laws approving the use of marijuana for medical reasons. This requires a special permit and a Doctor’s approval. However, while state government may allow the use of medical marijuana the Federal government still considers it illegal whether for medical use or not. Therefore doctors are wary of discussing or prescribing medical marijuana. Not only do the rules between state and federal government differ, the actual long-term health affects of marijuana is not well understood. For every study that quotes a therapeutic use another shows that long-term use can cause harm. Other studies suggest that marijuana interacts with other medications making it difficult for physicians to know whether the risks of using marijuana outweigh the benefits. Despite these concerns, medical marijuana is being requested by patients more often. This may be more common in certain populations or areas of the state. So not only are the uses of medical marijuana not well understood, the actual number of patients requesting or using medical marijuana is rapidly growing. In my project I will attempt to gain a better understanding of the patients who ask for or use medical marijuana by looking at certain variables such as the reason for requesting medical marijuana, the age, gender and other medications used. An attempt will also be made to estimate the total number of patients with medical marijuana cards in a small southern Oregon rural practice. I also hope to gain more information from clinics that specifically work with patients desiring medical marijuana cards. All this information will be gathered to gain a better, broader understanding of medical marijuana and those who ask for it.

Identifying the Disparity: A Comparison of HIV Resources between Curry and Josephine Counties and Multnomah County
Date of project: 9/8/2008

As with most health care resources, the HIV resources in rural communities are remarkably less available than more urban areas. This project attempts to qualify and quantify these differences and also attempts to provide an explanation for the differences in funding to these areas. Methods: The study uses interviews with patients, physicians and authorities from Josephine, Curry and Multnomah County Health Departments to identify key differences in these areas. It also uses analysis of the State of Oregon HIV Data and Analysis database. Conclusions: Although there are key differences in resources between rural and urban areas, the study concludes that the disparities are a product of supply-and-demand and a product of the algorithm used by the federal government for allocating dollars to these areas. It also concludes that there is incongruence in the incidence, prevalence and death rates of HIV in these areas, supporting the additional funding to urban areas.

The O & C: Unhealthy Drama in Rural Counties
Date of project: 9/11/2006

Josephine County is one of many Oregon counties facing the permanent loss of multimillion-dollar "O&C" federal funding, with resulting deterioration of services in public health and safety. Funding is currently set to expire October 1, 2006, midway through my rotation in Josephine County. To examine the impending problem, I attempted to answer whether Josephine County would suffer a severe undermining of its public health because of its largely rural population, and to pursue promising courses of action. Methods: Research involved interviewing the public health departments of Josephine, Douglas, Curry, Jackson, Lane and Clackamas counties on the projected changes, as well as a literature review about the determination of support for health programs and the relevance and precedents of public polls. Findings: While there are unique challenges and few recourses associated with being a rural county, Josephine County appears particularly unprepared. Discussion: The ideal strategy involves a tripartite approach of (1) population education on the role of public health (2) assessment of support for additional tax levies (3) increased alternative funding, taxes, and innovation in organizational structure. The former calls for a controlled, randomized, and validated telephone survey throughout Josephine County to assess what, if any, type of tax levy citizens would support and the demographics involved.

Medication Compliance in a Small Subpopulation of Elderly Patients in the Illinois Valley
Date of project: 5/1/2006

As patients age, their risk of developing chronic conditions such as hypertension, diabetes, and hyperlipidemia increases. These illnesses are manageable by taking medications, but eventually patients may find themselves taking multiple prescriptions which may actually make it difficult to treat their illnesses if they are unable to comply. One reason for this is that as people age they may have increasing difficulty remembering things and may not be able to keep track of many drugs. In a rural setting other factors such as low incomes and long distances may also play a part in medication noncompliance. The family practice clinic in Cave Junction, Oregon consists of almost 2,400 patients; 26% are over the age of 65 and several of them have multiple chronic conditions. The goal of this project was to determine whether there are barriers to compliance with taking medications in this rural community and to identify solutions to resolve them. Ten home visits and eight phone interviews were conducted to determine which systems patients use in remembering to take multiple drugs. Most patients had lists and/or pillboxes to help them remember and were taking everything as prescribed. It was therefore concluded that medication compliance in this small subpopulation of elderly patients is better than expected and that they are not currently plagued by barriers to compliance. Even though these patients are able to get their prescriptions filled now, however, they are worried about rising costs. Many of them are of low income and therefore struggle to pay for their medicines. Patients with Medicare Part D are particularly unhappy because they pay more now than they paid before it was implemented this year. Rising costs and the new prescription drug coverage plan may represent future barriers to compliance for these patients.

Examining Barriers to Physician Referrals to Hospice Care in Josephine County
Date of project: 2/13/2006

The goal of hospice care is to provide palliative care, symptom control, and emotional, spiritual, and social support for both patients and their families. Hospice services are meant to provide quality of life during the dying process. Lovejoy Hospice receives approximately 50% of referrals from area physicians and approximately 45% directly from families. These percentages either reflect a high public awareness of hospice services or that there are barriers for physicians when it comes to offering hospice as an option. Therefore, a survey was designed to help identify barriers in the physician community. The survey includes questions about physician and hospice interactions, the difficulties of discussing end-of-life care, the tools physicians would find helpful in an end-of-life discussion, and the awareness of the range of diseases and age groups that hospice can serve. The responses will be analyzed and, hopefully, barriers identified. With this data, strategies can be developed to aid physicians in overcoming barriers to offering patients hospice care as an end-of-life option. The desire to help physicians overcome barriers comes from the ultimate goal of ensuring that no patient goes without hospice care because the option was not presented to them.

Mental Health: Coordination of Care in Josephine County
Date of project: 5/10/2004

Access to and delivery of mental healthcare in rural America is a significant problem. According to the primary care providers (PCP) in Josephine County, OR, this is one of the most frustrating aspects of their practices. The family practice physicians felt that Josephine County Mental Health Department (JCMHD) was not adequately taking care of the mental health needs of their patients. JCMHD felt that they were doing a reasonable job of this and that their policies and procedures were well thought out and implemented with the blessing of the directors of the local independent physician associations (IPA). This project attempted to improve communication and understanding between the JCMHD and local PCPs in the area in order to help bridge the impasse that had festered. Multiple interviews were held with administrators at JCMHD and local PCPs as well as the director of one of the two local independent physician associations. Through these discussions, a proposal was made to the local IPA and JCMHD. The proposal includes four parts: 1. Same-day call back to the local PCPs from the psychiatrist. 2. Prompt feedback from the therapists after the patient’s initial visit either through a phone call or a fax. 3. Urgent slots with the psychiatrist will be made available for acute patient care. 4. A meeting to be held every four months with representatives from JCMHD as well as the directors of the two local IPAs. The local IPA is on board with the proposal and JCMHD is still reviewing the proposal, but seems willing to agree to it as well.

Evaluation and Management of overweight children in Cave Junction, OR: development of a patient/student handout to outline behavior modification strategies for patients and students at the local schools.
Date of project: 3/29/2004

Obesity is on the rise in the world, in the U.S. and in Oregon. Obesity and its complications and co-morbidities are poised to overtake tobacco as the leading “actual” cause of death in the U.S. And our children are right in the middle of the epidemic with the rate of overweight in Oregon’s teens tripling in the past 20 years. Objective: The aim of this study was to ascertain where the children in Cave Junction, OR fit in the larger picture of obesity. How many of the children in a rural Family Medicine practice are overweight and “at-risk” for overweight? Also, what interventions are available and what will be effective at helping these children maintain appropriate weights? Methods: The charts of the 208 children aged 2-20 years old that are seen at Cave Junction Family Medicine clinic were reviewed for heights, weights, gender and age of the children. Body Mass Indexes (BMIs) were then calculated using the CDC’s BMI-for-age and sex charts. Results: Of the 208 children found in the clinic’s database, only 113 of them had heights recorded. Two children (2%) were “underweight” (<5th percentile BMI for age and sex.) Seven children (7%) were “at risk for underweight” (5-10th percentiles). Fifty-eight children (51%) were “normal weight” (10-85th percentiles). Twenty-two children (19%) were “at risk for overweight” (85-95th percentiles.) And twenty-four children (21%) were “overweight” (<95th percentile.) The only BMIs in the charts were from transferred records. Conclusion: The children in Cave Junction are more overweight than the average child in the U.S. (21% in CJ vs. approx 15% in the U.S.) Also, BMIs are not currently being tracked in that clinic and there is good reason to do so.

Antibiotic Prescribing Practices in two community settings: Are Physicians in Southern Oregon practicing the judicious use of Antibiotics?
Date of project: 1/5/2004

Antibiotic resistance is a public health problem that could potentially affect our ability to treat infections like otitis media, acute sinusitis, acute pharyngitis, and pneumonia. The overuse of antibiotics and the inappropriate use of broad-spectrum antibiotics for acute upper respiratory tract infections contribute to the development of resistant strains of bacteria. The Oregon Department of Human Services reports that Oregon clinicians prescribe antibiotics for URI and pharyngitis at a lower frequency than the national average. However, Oregon physicians prescribe antibiotics more often for bronchitis and acute otitis media. The AWARE (Oregon Alliance Working for Antibiotic Resistance Education) campaign provides educational materials for clinicians and their patients promoting the judicious use of antibiotics in Oregon. In celebration of antibiotic resistance awareness week, January 25-31, 2004 and evaluation of antibiotic prescribing practices in Southern Oregon is performed to determine if, indeed, the message is getting through

Smoking Cessation in Josephine County: Identifying and Supporting People That Want to Quit.
Date of project: 7/7/2003

Smoking is one of the largest public health risk factors in this country. Millions of people partake in this habit which directly contributes to heart disease, cancer and strokes, the three leading causes of death. Fortunately smoking is a modifiable behavior but unfortunately nicotine causes one of the strongest addictions known. There is great need to accurately screen for smoking status and also to effectively treat patients’ addictions. Smoking rates are particularly high in Josephine county resulting in an estimated $61 million in health care costs last year alone. The purpose of this project was two-fold. The first goal was to assess the ability of Cave Junction Family Medicine, a rural clinic, to identify and document their patients smoking status. The second objective was to create a handout aimed at educating smokers on cessation techniques and resources. Smoking rates at the clinic were determined by a reviewing all of the patient records entered into “Amazing Charts,” their electronic charting program, which was implemented approximately 6 months ago. The data showed that smoking status was not recorded in over 17% of patients, particularly adolescents, and that 54% of patients with known status have some history of smoking. Recent data states that 75% of smokers in this state want to quit and 28% would like to stop in the next 30 days. These numbers would suggest that there is a great potential use for cessation information in this community. The results of this study have stressed the need for more aggressive smoking status assessment and have shown the need for an aid to increasing cessation efforts.

Meningococcal Disease: The Health Department Response and Community Awareness/Education
Date of project: 2/11/2002

This project was an educational experience in community public health and it was intended to gather data for improving methods for dissemination of information and awareness, following an isolated case of meningococcal meningitis. On the February 22nd, 2002, a case of Meningococcal meningitis was reported to the Josephine County Health Department, involving a 16 year old boy from the Illinois Valley High School. I observed first hand the steps taken by the health department to identify exposed contacts, notify each contact, and arrange for prophylaxis treatment. In the weeks following this case, I arranged a community forum to educate the community regarding the pathophysiology of meningococcal disease, the importance of early identification of symptoms, and the public health departments role in responding to this disease and arranging treatment to the community. It was also my goal to administer a survey at this meeting to gather data regarding the community's perspective on information dissemination and public health awareness. However, a less than expected turnout at this meeting made the survey unfeasible.

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