RCHC Community Project Abstracts

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Addressing Mental Health Care Needs in Clatsop County: The Impact of Inadequate Acute Crisis Management and Lack of a Safe Room
Date of project: 3/16/2009

In the face of state-wide budget shortfalls, an already struggling mental health care system is facing even greater challenges. The impact such shortfalls can have on small communities is substantial. In 2007, Columbia Memorial Hospital (CMH) received 14,500 emergency room visits, of which 1,300 were for either drug or alcohol issues or for patients in need of psychiatric stabilization. Two major issues currently limit the delivery of adequate acute psychiatric care in Clatsop County: the lack of a state-licensed safe room and psychiatry service at CMH. Under the current system, patients presenting to the emergency department are escorted by law enforcement, leaving the community short one-to-two officers. Emergency department physicians are unable to administer psychiatric medications to unstable patients, so the patients are stabilized by sedation and then released without follow-up. When these patients require further psychiatric care, they are put in handcuffs and are escorted by local law enforcement to an out-of-area hospital capable of managing the situation, risking further destabilization of the patient. Establishing a safe room in Clatsop County as well as implementing a telepsychiatry program would address these issues and would decrease the long term financial cost to the community through more efficient use of resources. Most communities using telepsychiatry report high levels of satisfaction. Additionally, the current literature seems to support that the quality of care delivered by telepsychiatry is comparable to in-person care. Although there are challenges, including up-front costs involved in establishing a telepsychiatry program, these are outweighed by the benefits such a program would provide to the local community.

Enriching the Cancer Dialogue: The Development of a Patient Handout that addresses underlying roadblocks against parental acceptance of the HPV Vaccine
Date of project: 12/29/2008

Cervical cancer remains the second leading cause of cancer-related deaths in women across the globe. In the United States alone, it claims the lives of 3,700 women each year. Infection by the human papillomavirus remains the leading cause of cervical cancer. Since the 2006 release of the first FDA approved HPV vaccine, marked controversy has emerged surrounding the administration of the vaccine to young adolescent girls in an attempt to target women prior to their first sexual encounter. This has led to diminished acceptance of the vaccine by parents as their daughters approach adolescence, a trend clearly observed in a rural Oregon community at a time when rural areas continue to mark the highest yearly incidence of HPV infection. Attempts to identify roadblocks to parental acceptance of the HPV vaccine were made through observation of patient encounters coupled with an examination of online parenting blogs and forums and augmented by a search of the medical literature. The final product of this project stemmed from the information gathered in the creation of a new patient handout that more directly addressed the most important underlying concerns expressed by parents who were reluctant to accept the HPV vaccine’s administration to their daughter.

Inpatient Hospital Resources in Astoria, OR: Development of a Patient Library
Date of project: 10/13/2008

Patient education is a critical part of effective healthcare delivery. Although patient education begins with healthcare workers, it must be reinforced by other modalities including pamphlets, books and the internet. This study aided in the completion of a patient library for inpatients at Columbia Memorial Hospital in Astoria, OR. The design was consisted of observation of patient care and exploration of current resources at CMH, meetings with the Stewards, data collection of population demographics and inpatient diagnosis. To aid in its completion, this project consisted of (1) Instructions of how to access WebMD for a novice computer user; (2) Pamphlets for the most common inpatient admissions at Columbia Memorial Hospital; (3) Development of a handout of patient friendly websites. These resources, including the internet, are cost-effective teaching tools. Increasing patient education will hopefully translate to increased compliance, improved patient-physician relationships, and greater patient autonomy.

Can Astoria Support a Physiatrist?
Date of project: 6/30/2008

Rural communities are disproportionately affected by disabling conditions and chronic diseases. Labor-intensive occupations, older demographics and shortages of medical services contribute to faster progression of disease in rural settings. To address these issues, Columbia Memorial Hospital became interested in the viability of a physical medicine and rehabilitation specialist in Astoria. One of the most significant factors to the success of physiatrist is whether this specialist can obtain referrals from primary care clinicians. The purpose of this study was to assess the attitudes, potential competition, past referral patterns, and predicted referral patterns of clinicians in Astoria and Seaside with respect to physiatry. The majority of surveyed clinicians self-report a high degree of familiarity with physiatry. They are comfortable referring patients to this field and they believe physiatry would provide unique services to the area. While some are concerned about competition with a physiatrist, the overall attitude from local clinicians is supportive of this addition to Columbia Memorial Hospital. While an adequate referral base may exist locally, the catchment area for this specialty can extend beyond Astoria and Seaside to ensure a sustainable number of patient encounters. Educating primary care clinicians about physiatry and cultivating relationships with colleagues in the service area should provide adequate referrals to support this addition to Columbia Memorial Hospital.

Access to Mental Health Resources in the Astoria Area, A Narrative Survey.
Date of project: 3/17/2008

Mental health complaints are extraordinarily common in the primary care setting with a prevalence of up to 50%. Primary care physicians do the bulk of routine mental health care in all settings but this is particularly true in rural areas. What resources are available to them when they have patients requiring more specialized care? A qualitative survey of mental health care resources in the Astoria was done. Many of the obstacles to care were found to be similar to those of an urban environment: poor access for the uninsured, providers unwilling to accept Medicare patients. Other obstacles were more unique to a rural area, specifically the lack of local inpatient psychiatric beds and certain other specialized psychiatric services such as methadone maintenance clinics or inpatient treatment for eating disorders. Overall PCPs in Astoria have ready access to such referral services as counseling and therapy as well as to psychiatric prescribers. Overall all of the health care providers surveyed seemed to enjoy the benefits of living and working in a small town.

Emergency Preparedness of Non-hospital Medical Offices in Astoria, OR
Date of project: 12/31/2007

The problem studied is emergency preparedness of non-hospital medical offices in Astoria, OR. The population in question includes all the residents of Astoria. The methods used include in person interviews of physicians and office managers. The findings are that there were few offices that were prepared for a recent local disaster. This has however, brought to light the importance of a disaster plan for non-hospital facilities. The final product of this project is a plan of action for the education and collaborative disaster planning by local physicians' offices and the emergency preparedness/safety coordinator of Columbia Memorial Hospital.

Diabetes Education Handout
Date of project: 8/6/2007

The number of people with Type 2 Diabetes is increasing in the United States. It is a major contributor to overall morbidity and mortality in the Untied States and in Astoria Oregon. There was an average of 41.8 deaths per year (17.5% of all deaths) caused by diabetes between 2000 and 2004 in the Astoria service area1. Following diabetes management guidelines can help decrease the associated morbidity and mortality of type 2 diabetes2.This study attempted to identify information that would be helpful in educating patients about newly diagnosed diabetes and compiling the information into a one page handout. A family doctor in Astoria was observed counseling newly diagnosed diabetics. Educational material for diabetics was reviewed. A handout for patients with diabetes was the end product.

Does Astoria Have A Physician Shortage?
Date of project: 4/30/2007

Collaboration with the Community Health Improvement Partnership yielded a method that allowed assessment of a possible physician shortage in Astoria, Oregon. A survey of the local physicians enabled the team to identify the number of physician resources available in the rural town. After the data were collected, the amount of need for provider resources was determined based off of published population studies. In conclusion, the project revealed that there was a shortage in specialty physician resources, including but not limited to: cardiology, oncology, gastroenterology, and dermatology. Interestingly though, the population comparisons demonstrated that there were adequate visits for and number of primary care physicians.

No More Excuses
Date of project: 3/19/2007

Type II Diabetes and Obesity are increasing in incidence at an alarming rate. It has been well established that diet and exercise is the treatment of choice for obesity and type II diabetes. This study attempted to identify the effectiveness of treating and managing type II diabetics with diet and exercise. The design was to document each diabetic patient seen over a 5-week period, the date they were diagnosed with diabetes, their BMI and HbA1C at diagnosis and their current BMI and HbA1C as well as the medications used to treat their diabetes. When able, patients were questioned as to reasons why they chose to not exercise. These values were put into a chart from which came the results: How many patients have managed to successfully treat his or her diabetes with diet and exercise alone. Finally, a pamphlet was made to help aid providers in educating patients on the benefits of increasing physical activity through little effort on behalf of the patient.

Heart Disease and Diabetes Handout for Kids
Date of project: 1/1/2007

Heart disease and Diabetes are two of the most common diseases now present in the U.S. In the National Health Survey of 2004, the percent of non-institutionalized adults with diagnosed heart disease was 11.5 and the number of annual deaths was 654,092. In 2004, heart disease was responsible for 1/3 of all deaths. Diabetes is also of epidemic proportions. Approximately 7.2 million people have Type II Diabetes in the U.S.(actually diagnosed). According to the National Diabetes Statistics fact sheet, (NIDDK of 2003) approximately 1 in 17 or 5.88% or 16 million people in USA have diagnosed and undiagnosed diabetes. Diabetes is the nation's seventh leading killer and contributed to about 187,800 deaths in 1995 Two known risk factors for these diseases include smoking and obesity. Despite this, the incidence of obesity in adults and children continues to rise, and smoking has increased in young adolescents. For these reasons, we feel it is extremely important to begin educating young children about heart disease and diabetes, and give them basic tools to avoid these diseases. To accomplish this in the rural family practice setting, a children's book was created which outlines the basics of these diseases and encourages healthy eating, exercise and not smoking as three methods to help prevent heart disease and diabetes. The book will be used in the office setting as a tool to open up conversation and learning opportunities around these issues. In addition, a one-page handout summarizing the above will be given to the patients to take home as a reminder of what they learned. This is the beginning of an early education regarding the importance of lifestyle choices in the future health of our nation.

Effectiveness of hypertension management in Astoria, OR.
Date of project: 10/16/2006

Hypertension (HTN) incidence and prevalence continues to increase across the country, with a higher disease burden found in some rural areas. In fact, it was the most frequent diagnosis recorded for all routine health checks (4.1%) in the US, and in a small Family Practice clinic in Astoria, OR, HTN was the reason for 6.1% of visits per day. However, recent studies show only 20-30% of those with HTN have optimally controlled blood pressures (BP). I researched current recommendations for successful management of HTN in the literature, and used this information to investigate the effectiveness of HTN management in this small Family Practice clinic in Astoria, OR. A flowsheet was created to focus on these guidelines and a chart review of 35 patients was done using this tool. Data was collected, including weight, BMI, BP, risk factors/secondary causes, PE and labs done, medications, and expected follow-up. Results showed that these two Family Practitioners did an outstanding job of overall BP management, with almost ¾ of their patients at or below their goal BP, and timely lab follow-up. Areas of improvement include stricter use of recommended medications for specific co-morbidities, consistently including fundoscopic exam as part of the PE, and ordering EKGs. This information can be used as a background for future HTN management in this clinic, with utilization of the flowsheet to aide in the improvements discussed.

Weight loss interventions in Astoria, OR: development of a patient resource guide to connect patients with weight loss resources in the community.
Date of project: 8/7/2006

With over 60% of Americans classified as overweight or obese, a significant portion of our population continues to share an elevated risk for obesity related conditions such as diabetes, hypertension, coronary artery disease, arthritis and sleep apnea. Through this project, I hoped to identify ways in which physicians could support their patients who are trying to lose weight. Exploring this question involved observing how my preceptor in Astoria discussed weight loss with her patients. I then created a list of simple, cost effective ways a family physician could support weight loss among a patient population. An interview was conducted with my preceptor and her practice partner to learn how willing they would be to implement various weight loss interventions. I spent one morning at Curves, a chain fitness center that offers circuit training and is attended mostly by women. Willing participants were interviewed regarding weight loss and how doctors could support weight loss efforts. Interviewees were also asked to evaluate how helpful it would be if their doctors implemented various specific weight loss interventions. Of the many interventions suggested, patients and doctors were most excited about the availability of a booklet that presented information on local resources for weight management. Therefore, the project culminated in the creation of "Health Knocks: A Resource Guide to Weight Management in Astoria, OR". This tool will help physicians to connect patients with weight loss resources n the community.

Assessment of Housing and In-Home Care Options for Seniors in Astoria
Date of project: 5/1/2006

In Clatsop County, the percentage of the population over the age of 65 was 15% in 2005, but this number is projected to increase to 24% by the year 2025. The need for long term-care services is steadily increasing as well. Initiating the conversation about the need for more assistance in the home can be difficult for seniors and their families. Furthermore, once the decision has been made, determining the level of care needed and researching the options is complex. Within Pacific Family Medicine, it has been observed that seniors and their families are uninformed about the housing and in-home care options available in their community and lack adequate resources to make informed decisions about long-term care. The purpose of this project was to provide information about different types of housing and in-home care options for seniors, facilitate discussion between families about the need for more assistance in the home, and provide tools to help people assess their level of need and evaluate their options. The final product of this project is a resource guide to be utilized by seniors and their families.

Medical Information Researched via the Internet by Patients in Astoria, Oregon: To surf or not to surf...that is the question
Date of project: 2/13/2006

The Internet has become a vast resource of medical knowledge for patients all across the United States. This study sought to characterize the level of Internet use with respect to acquiring medical information in an Astoria, Oregon family practice clinic. The study design was based on three individual components: First observational data obtained from patient interactions, second qualitative and quantitative data obtained from patient surveys and finally anecdotal evidence from interviews with physicians. The results indicated a high percentage of patients acquiring information from the Internet. Review of current literature validated our conclusion further quantifying the types of information obtained and the results of acquiring such information. Given the possibility of negative outcomes as a result of false information, a patient brochure was designed to help physicians educate patients on how to obtain credible information on the Internet with the inclusion of disease specific sites.

Effectiveness of Type 2 Diabetes management in Astoria, Oregon
Date of project: 10/17/2005

The management of type 2 diabetes represents a unique challenge for Oregon’s rural practitioners. Death rates among diabetic patients in Oregon have steadily increased, with much of the disease burden resting in rural communities. In Clatsop County, the death rate from diabetes is staggeringly high, at 40.8 per 100,000 people – a rate almost double the national average. In attempt to address this issue, I investigated the management of type 2 diabetes mellitus at a small, private family medicine clinic in Astoria, Oregon. A chart review was performed of fifty patients with the diagnosis of type 2 diabetes, with a focus on three components of diabetic care: 1) glycemic control, as measured by HbA1C, 2) cardiovascular risk management, and 3) the assessment, prevention, and treatment of diabetic complications, specifically retinopathy and nephropathy. The results of the review revealed several areas of possible improvement in diabetic monitoring, in addition to highlighting the importance of medical therapy with aspirin, ACE inhibitors, and lipid-lowering agents. Several barriers to optimal diabetic management were identified, with the primary impediment being patient non-adherence to diabetic treatment and follow-up regimens. This data should serve as a background for future endeavors in the clinic, with the eventual goal of developing a better tracking system for diabetes management.

Complementary and Alternative Medicine in Astoria, Oregon: Examination of community needs and practices, with creation of a patient handout to aid in discussion and decision-making.
Date of project: 8/8/2005

This project examined the frequent use of complementary and alternative medicine among patients at the Pacific Family Medicine clinic in Astoria, Oregon. The availability and knowledge of information for physicians and patients on alternative medicine was assessed and found to be in need of improvement. A set of pamphlets was created that provided advice on decision making regarding alternative medicine, listed useful resources, and provided some specific information on selected alternative therapies, medicines, and supplements. These handouts were distributed to the providers at the clinic for use as patient handouts, references, and discussion aids.

Mental Health Resources in Clatsop County: A Summary of the Need For and Existing Mental Health Services
Date of project: 3/21/2005

Mental health disorders and the need for mental health services are pervasive in all areas of Oregon, including rural communities like Clatsop County. Residents of Clatsop County have a greater proportion of alcohol and drug-related problems and have at least equal to or greater need for other mental health services. Despite the need for mental health services, resources are seemingly lacking, and furthermore, resources are not readily evident to local health care providers who must often align their patients with appropriate mental health services. The goal of this project was to examine the scope of the need for mental health services in Clatsop County, identify mental health resources in Clatsop County, formulate a pamphlet for use by local health care providers and community members which summarizes existing mental health resources, and approximate whether current resources adequately meet the needs of the population with mental illness.

Screening and Intervention for Psychosocial Risks: Analysis of Barriers to Appropriate Utilization of Social Services for Obstetric Patients in Astoria, Oregon
Date of project: 2/7/2005

Most communities have social services available to, or directed towards the Obstetric population when they are identified as having specific needs. Unfortunately for the community of Astoria, Oregon, the obstetric patients in need may not be aware of the social services available to them. To further complicate the problem, there are no dedicated obstetric social workers in this community to identify high risk Obstetric patients and help them access and navigate the systems that administer these services. The individuals that are called upon to help obstetric patients connect with available resources are the health professionals caring for these patients such as the nurses, midwives and obstetricians, who are already overworked in their existing roles. This community project includes a survey of social services that are available to obstetric patients in the community of Astoria, Oregon: current methods used to identify patients with needs and facilitate connecting patients to these services; and based on this research, recommended changes to improve this process. A comprehensive list of the available social services was compiled to improve patient and provider awareness of available social services.

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