RCHC Community Project Abstracts

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Swine Flu Epidemic: What are patient and health care workers attitudes and knowledge of the H1N1 influenza and vaccine in Florence Oregon?
Date of project: 10/12/2009

The H1N1 flu is an epidemic that has already reached 48 states, and has killed 672 people, and hospitalized over 17,000 (1). Patients are asking about the H1N1 flu and vaccine on a daily basis and many are very concerned. Health care workers are also frequently discussing these issues. Two surveys were developed to question the opinions and knowledge base of both patients and health care workers regarding the H1N1 flu and vaccines. There appears to be some lack of knowledge about the H1N1 vaccine and flu. People of all ages are concerned about the flu, and age doesn’t determine who thinks they do or do not need a vaccine. The majority of people are receiving information from the television about H1N1, and very little from their doctor’s office. There is a need for greater patient education about the vaccine and the flu. In regards to health care workers that were surveyed, doctors are well vaccinated, and MA’s are not. Many patients (on average 50% or more) are asking about the vaccine and flu. Most workers are providing very minimal information to patients regarding the vaccine and flu. Workers are being approached by family members and the community about the vaccine and flu. Only 13% of workers feel they are confident of their knowledge of the vaccine and flu. In conclusion, patients and health care workers are in need of education about the H1N1 flu and vaccine. Preparation and prevention are key concepts for health care workers and patients to understand (2).

How effective is dyslipidemia screening in the Peace Harbor Family Medicine Clinic?
Date of project: 9/7/2009

This study looks at the prevalence of dyslipidemias in a Family Medicine outpatient clinic in Florence, Oregon. The Peace Health electronic health record was used to identify adults 18 and older with at least one dyslipidemia; lower than recommended for HDL, or higher than recommendations for total cholesterol, LDL, or triglycerides. Medication lists were used to identify those receiving treatment, including omega-3 fatty acid supplements, statins, niacin, fibrates, etc versus those with no cholesterol treatment listed. 86.8% of patients in this population were found to have at least dyslipidemia, and 59.3% of these patients were receiving treatment. A patient handout on dyslipidemias, treatment, and the importance of screening was designed from this information.

Challenges to providing psychiatric care in Florence, OR– Is telemedicine an option for the future?
Date of project: 4/27/2009

Mental health resources are already lacking in rural communities and by mid 2009, the two visiting psychiatrists who come to Florence every week will phase out their practices there. With this drastic change in psychiatric services, alternatives need to be explored in order to adequately care for the mental health patients in Florence. Additionally, it is important to investigate why these psychiatrists are leaving and what difficulties they have faced trying to practice in a rural setting. Interviews with two psychiatrists who currently see patients in Florence were conducted and literature search on telepsychiatry was done. It was found that there are financial, logistical, political and geographical reasons that make the practice of psychiatry in Florence, Oregon difficult. The departing psychiatrists believed their absence from the challenging patient population in Florence will create great stress on primary care providers, be traumatic for patients, and cause difficulty for children in school. There is a growing body of literature that supports the use of telepsychiatry as equally reliable at diagnosing and treating a variety of mental health problems while keeping patients out of the hospital and being cost effective. It is also financially feasible from a reimbursement standpoint with the passage of senate bill 24 in Oregon as well as a good source for the education of primary care providers.

Investigating primary care provider perceptions and practices regarding smoking cessation in Florence, Oregon; and the development of a cost focused informational pamphlet
Date of project: 12/29/2008

Rural areas have been shown to have higher rates of tobacco use than urban or suburban areas.(1) These higher rates have led to significant morbidity and mortality in rural populations.(3) Although state and national data has shown declining smoking rates over the past several years, these declines have not occurred as rapidly in rural areas.(2) Previous studies have found that rural smokers tend to want specific smoking cessation counseling from their doctors, including medication costs, efficacies and a specific plan.(2) This study investigated the perceptions and practice patterns of primary care physicians in Florence, in order to assess which smoking cessation tools were being used and whether Florence providers give specific weight to issues like cost and efficacy. Questionnaires were given to Family Medicine and Internal Medicine physicians concerning smoking cessation. These questionnaires showed that providers find smoking cessation to be an important goal, but that they may be underestimating the number of smokers in their practices. All of the providers mentioned patient motivation and willpower as barriers to smoking cessation, while two mentioned the cost of the therapies. Half of the providers preferred Chantix to other pharmacotherapies. With the goal of providing specific information to patients on cost and effectiveness of the different smoking cessation options, a pamphlet was developed for provider and patient use during counseling.

Rate of Immunization in Florence and Parental Concerns Preventing Complete Immunization in Children at the PeaceHealth Family Medicine Clinic
Date of project: 10/13/2008

Childhood vaccinations remain an important tool in preventing disease in individuals and populations. For example, since the introduction of the Hib vaccine, there has been an 80% decrease in invasive Hib disease. However, vaccines have recently been at the center of a media storm due to a hypothesized link between vaccines and autism. Much work has gone into researching this link and there is solid evidence to reject the causal hypothesis between the MMR and autism, however parents remain concerned. This project seeks to look at the rate of immunization in the rural coastal community of Florence according to the CDC vaccination schedule of 4:3:1:3:3:1 by age two and the barriers that exist to complete immunization. Here, I report that Florence has an immunization rate of 72% in 2006, which is similar to Lane County and Oregon rates, but remains below the national average. Furthermore, the physicians at the PeaceHealth family medicine clinic in Florence report the three most common concerns of parents that potentially prevent complete immunization are concern about autism, concern about the mercury-containing preservative thimerosal and concern about immune system overload. I summarized the evidence that dispels these three common myths in a brief handout for parents.

A Welcome Home: Needs Assessment and Projected Cost Analysis of the Addition of a Behaviorist to the Primary Care Home in Florence, Oregon
Date of project: 9/8/2008

According to a 2002 study published in JAMA, “Most people in the United States want a medical home.” As the PeaceHealth Siuslaw Region Family Medicine practice makes plans to move forward with its version of a Primary Care Home, a needs assessment and a projected cost analysis were performed to determine the probable clinical and financial outcomes of adding a behaviorist to the care team. The design of this study was direct observation of the practice of one of the ten family physicians currently working at the PeaceHealth Family Medicine Center. At the conclusion of each working day, the patient census was analyzed; based on presenting complaints, chronic health problems and length of individual visits, we sought to determine which patients would have benefited from a consultation with a behaviorist. Based on average Medicare and Medicaid reimbursements for both physician office visits as well as Health and Behavior codes, we were then able to estimate the projected financial impact of these determinations. Our findings demonstrate that a behaviorist is a necessary and, in the worst-case scenario, a cost neutral addition to the Primary Care Home in Florence, Oregon

The Use of Pre-Printed Order Sets for Inpatient Community Acquired Pneumonia Treatment to Increase Compliance with National Quality Measures in a Rural Hospital
Date of project: 8/4/2008

Physician order sets for specific inpatient diagnoses are a potential method to decrease the incidence of medical errors. Computerized physician order entry (CPOE) is the gold standard of order sets and has been shown to decrease adverse events in larger hospitals. However, the cost of implementing CPOE is often financially infeasible for smaller, rural hospitals. An alternative is to CPOE is the use of pre-printed physician order sets for inpatient treatment. This study analyses the use of pre-printed order sets for meeting national quality measures for the treatment of community-acquired pneumonia in a 21 bed rural hospital located in Florence, Oregon. The data set collected was too small to draw any conclusion whether pre-printed order sets increased compliance with national standards. However, the pre-printed order set was used on only 22% (7/32) of pneumonia patients in the study. Increasing physician usage of the order set will be necessary to determine if pre-printed order sets are more effective in achieving national benchmarks.

Screening for Depression in the Elderly in the Primary Care Setting: Piloting the Use of a Two-Item Questionnaire in Florence, OR
Date of project: 4/28/2008

Depression is a major health issue among the elderly, with approximately 10% of adults aged 65 or older suffering from clinically significant depression. This problem is particularly relevant to Florence, OR, which has a large and growing retirement community. A major obstacle to addressing this issue in the primary care setting is that of efficiently screening for depression in a geriatric population with many co-morbidities that can confuse or overshadow mental health issues, and limited time to administer screening tests. Currently, elderly patients at the Florence family practice are only screened for depression at certain visits, such as annual diabetic exams. This project piloted the use of the two-item Patient Health Questionnaire 2 (PHQ-2) among all elderly patients visiting their family practice doctor in Florence, OR as a brief, efficient means of identifying depression in this population. The screening questions were verbally asked of patients age 65 or older, and the questionnaire results were analyzed to determine both total rate of positive screens and the number of these that were previously undiagnosed as depressed. The results of this pilot use indicate that incorporating the PHQ-2 into regular screening of elderly patients visiting the clinic could substantially improve detection of depression in this demographic.

An Assessment of the Teen Birth Rate in Florence, OR
Date of project: 2/11/2008

Florence, OR is largely regarded as an elderly community where people go to age gracefully. In a population where nearly twenty percent of its citizens are over the age of sixty-five years old, a public heath problem continues to brew quietly among a younger generation. The teen birth rate in Florence and surrounding areas is 1.7 times higher than the State’s rate, a statistic that appears even more exaggerated within this elderly community. Yet even among health professionals there is disagreement as to whether or not there is a problem with teen pregnancy in Florence. This project is an assessment of those perceptions and an evaluation of the availability of specific resources for sexually active teens such as contraceptive methods, emergency contraception, abortion, and adoption services. While access to all of these resources was found to be limited, the most underutilized was emergency contraception. Suggestions are offered as to how a subsequent project may be able to provide help in improving access to key resources and/or improve cooperation between Siuslaw High School and the Center for Women’s Health in generating a school-based clinic or outreach program. Barriers to such changes and a look at the historical aspect of this dilemma are also offered.

Access to Cancer Support Services in Florence, OR
Date of project: 12/31/2007

A diagnosis of cancer can be traumatic for a patient, and psychosocial support services have been found to help patients through their battle with cancer. Rural communities present a challenge when trying to provide cancer support services because of limited resources, traveling distances for the patients and the volunteers, and lack of a structure to educate patients about resources. In Florence, OR, a town with an elderly population that is greatly impacted by cancer, psychosocial support services are abundant, but often underutilized. In January, during my rotation, a new Cancer Resource Center (CRC) opened in Florence as a partnership between the American Cancer Society and Peach Health Medical Group. Its mission is to connect cancer patients with the available resources in the community. I decided to investigate the level of awareness of cancer support services among my preceptor’s patients and to work towards connecting patients in the clinic with the CRC. Through interviews with patients in my preceptor’s clinic, and with several individuals involved with the CRC, I concluded that there is a great need for the CRC in Florence and that patients are receptive to the idea of the CRC. The final product of my project was the creation of a referral form that can be used in the exam rooms at the time of cancer diagnosis to direct the patients to the CRC for educational and psychosocial support.

“Revenge of the Turquoise Blob” or "A Toxic Algae Bloom in Siltcoos Lake"
Date of project: 9/10/2007

Siltcoos Lake located 6 miles south of Florence, OR is the sole source of drinking water for approximately 300 people who live on or near it. It also serves as a recreational destination for fishing, swimming, camping, and boating. On September 18th, 2007 an advisory was issued for residents to avoid all contact with the waters of Siltcoos Lake due to a toxic algae bloom. This project attempts the following; 1. Identify the potential health risks associated with contacting or ingesting waters contaminated with toxic blue-green algae. 2. Estimate the actual numbers and types of illness that might be attributable to exposure the Siltcoos waters. 3. Identify resources for health care providers that help them to recognize blue-green algae toxicity, and resources that aid in treatment of toxic exposures.

Cycling in Florence, Oregon
Date of project: 8/6/2007

Cycling is an excellent form of exercise, with physical, mental and environmental benefits. Many of the most common causes of morbidity and mortality have improved outcomes in patients who exercise on a regular basis. Florence, Oregon is a small, coastal town with an older retirement population. Many people in Florence suffer from chronic diseases that could be improved with exercise. This study attempted to identify the current perceptions of, barriers to, and support for cycling among older adult chronic disease management patients in the family practice clinic in Florence. Additionally, an environmental survey of Florence’s cycling amenities was done, revealing a mostly flat, small town with low traffic streets and well maintained multi-use paths. There is also a full service cycling shop with an owner dedicated to promoting cycling in Florence. Most barriers to and negative perceptions of cycling identified in this project would be combated by cycling education and skills training in either group or one-on-one setting. This process was started with a resource book created for this project including safety information, local and online resources, local maps, a biking activity, and copies of several articles with evidence for the benefits of cycling in older adult populations.

Parent education initiative in Florence, OR: Development of a school newsletter that accurately addresses important child health education issues;
Date of project: 4/30/2007

Lack of basic child health education is a problem in many small towns. This study attempts to determine what areas of knowledge are most lacking, as well as which topics are the most important for parents in Florence Oregon to learn about in order to improve the health of their children. Parents, children, local physicians and medical office staff were interviewed and internet research was done to answer these questions. The end goal is to create a newsletter that will be sent home to all parents of school-aged children for the purpose of improving their base level of knowledge so that they have the tools necessary to make healthy parenting decisions.

Assessment of Resources Available for Persons with Dementia in Florence
Date of project: 1/1/2007

The population of persons over 65 is rapidly growing in the United States and this is especially true in rural communities, such as Florence, where this population makes up close to 40% of the total population4. One family practice clinic in Florence had close to 45% of its patients over the age of 655. Naturally, this would increase the number of age-related diseases, such as dementia, seen in this clinic compared to an average practice. Therefore, it is important for physicians to have easily accessible resources for themselves as well as for their patients. A resource guide was produced to help health care providers in the clinic better serve their patients with dementia.

The Bridge Assistance Program: Improving access to necessary health care in Florence, OR
Date of project: 8/7/2006

Access to health care is a problem in rural communities no less than it is in cities. Indeed, rural communities often have fewer organizations and resources to assist people in accessing health care than do their urban counterparts. As the primary source of medical care in Florence, Oregon, the Peace Harbor Hospital and Health Associates utilize an innovative program to assist those members of the community who would otherwise fall through the cracks among private means, insurance and social programs. The Bridge Assistance Program provides medically necessary services to patients at reduced or no cost once it has been determined that payment for those services cannot be obtained from outside resources. The program focuses on providing preventive and early care in order to reduce costs related to acute care and collections processes. This project explores the criteria used to determine eligibility for the program and the types of health care the program helps patients to access. Patient feedback was analyzed to determine the circumstances that led patients to seek assistance from this program, the satisfaction patients have with the assistance they received and what patients believe the program could do to improve. Study results found that the Bridge Assistance Program serves a vital role for patients who cannot afford necessary health care and do not qualify for sufficient assistance from other aid programs to meet their medical needs. Patients were generally very satisfied with the assistance they received from this program, though lack of dental and vision services at Peace Harbor as well as the high cost of prescription medications continue to be factors that limit access to health care for these patients.

Use of Herbal Remedies in Florence, Oregon: Helpful or Harmful? A Patient Handout to aid in discussion of natural supplements.
Date of project: 5/1/2006

Over the past twenty years there has been a resurgence in public interest and use of complementary and alternative medicine. Although natural, herbal supplements are pharmacologically active and have the potential to both help and harm the patient. While in Florence I attempted to identify those who are using natural supplements and determine if they had discussed their use with their physician as well their reasons for using the supplement. The design was a chart review of all patients seen by one physician during the month of May to determine who had natural supplements on their medication list and to determine what herbal remedies are used most commonly. Informally, patients that were taking herbal medications were then asked if they were aware of any potential interactions or side effects of the medications and if they felt the medication was effective in treating the condition they expected. Many voiced concerns over not knowing the purity and potency of the herbal supplements they were taking or what recent research shows about the efficacy of the supplement. The purpose of the study was to gather information and design a patient handout that would be targeted appropriately to the patient population at the outpatient clinic to encourage open discussion of natural supplements between a physician and patient, as well as provide a brief synopsis of the most commonly used herbs and recommendations on further reading.

Where did you get that idea? Developing an Integrated Strategy for Patient Information Handouts
Date of project: 1/2/2006

The brief time allotted to office visits limits patient education on acute primary care issues. Many practitioners rely upon written information they can give to their patients to follow at home. This study attempted to define a strategy for creating and refining patient education handouts in a Florence, Oregon family medicine clinic. While there were plenty of patient handout materials already existing in the clinic, these were often out-dated or otherwise inappropriate for use. The design was to work with physicians to identify areas where handouts were needed, articulate core concepts that physicians wished addressed, elicit patient feedback on handout materials and create handouts to satisfy these specific goals. Finally, further thoughts on extending the project were considered.

A Suggested Protocol for the Management of Recurrent Refractory Migraines in a Rural Setting
Date of project: 4/25/2005

Chronic Migraine patients frequently visit physicians (via the clinic or the emergency department) seeking parenteral treatment for severe acute pain. The workload placed on doctors due to this illness – combined with questions surrounding the administration of recurrent narcotics – causes controversy and friction among providers regarding the optimal treatment of these patients. The scope of this clinical issue in the town of Florence, Oregon, is investigated via discussion with clinicians and chart review of one physician’s census of chronic migraine patients. Algorithms based on available evidence are suggested for the management of chronic severe migraineurs in order to a) reduce the number of visits to the clinic and emergency department for acute parenteral treatment; and b) offer effective alternatives to IM narcotics when patients do come to a provider for said treatment.

Preventative Health Maintenance in Asymptomatic Men of Florence
Date of project: 3/21/2005

Men are more likely to die from 13 of the top 15 causes of death. Despite this, men are more likely not to visit a health care professional than women. The reasons are varied, but I believe a significant cause is lack of health knowledge. I believe that the use of mass media can be a useful tool to assist in educating asymptomatic men about health care issues. The focus of my project was to determine what screening and interventions would be most useful to the asymptomatic male. Recommendations are derived mostly from the USPSTF. I then published this information in the local paper so they would have a checklist of preventative health items. To determine the effectiveness of my project, I would propose that the PCPs in the area keep track of new patients and their motivation for visiting.

Nonpharmacological resources for the treatment of fibromyalgia in Florence, Oregon
Date of project: 10/18/2004

It is estimated that 3-5% of the population has fibromyalgia. The chronic pain of this condition has been a burden for patients and clinicians as pharmacological therapies are frequently insufficient. This project seeks to identify nonpharmacological treatments supported by the literature and present in Florence, OR. Furthermore, patients’ current use of these methods was investigated. Finally, a list of resources was supplied to clinicians for use in their practice in order to improve symptoms for the fibromyalgia community of Florence, OR.

The rising cost of prescription medications continues to impact the lives of many individuals.
Date of project: 9/13/2004

The rising cost of prescription medications continues to impact the lives of many individuals. It is one thing to hear that prescription medications are expensive, it is quite another to put a name and a life to the out-of-pocket cost than an individual has to pay in order to maintain health. The majority of prescription medications are utilized by individuals greater than 65 years old. In the retirement community of Florence, individuals 65 years and older represent 35% of the population and also represent the fastest growing group of individuals. In order to better understand the impact of the price of prescription medications on the elderly population of Florence, the aims of this study were to 1) determine the average out-of-pocket price of medication for individuals on Medicare or Private insurance; 2) research the price of commonly prescribed medications; and 3) to conduct a survey in order to better appreciate the impact of the cost of prescription drugs on patients in Florence. This experience not only helped me to become more aware that simply writing a prescription for a medication was not necessarily going to mean that a patient was going to be able to take the medication. Lastly, through observing patients as well as my preceptor, I learned that there are alternative ways to obtain prescription medications in order to ensure that patients are able to receive the medicine that they need to maintain health.

Delivery of and Attitudes About Hospice Care in Florence, Oregon
Date of project: 3/29/2004

Hospice services are widely underutilized nationwide, despite the desire of the majority of patients to die under hospice care. With this project, I was interested in determining the current utilization of hospice services in Florence, Oregon, as well as the attitudes of the general Florence population about hospice services. The design was a written survey of random patients within a family medicine practice at Health Associates of Peace Harbor in Florence. I also interviewed the intake nurse at Peace Harbor Hospice, which yielded information about the current utilization of and services provided by the hospice program. Although there was already good penetrance of hospice within the community, the average length of stay was shorter than desired. The survey indicated that the majority of patients would prefer to die in their own home under hospice care, but that most patients were not aware of the Medicare Hospice Benefit. Opinions of hospice care by those who had known someone on hospice were overwhelmingly favorable. Concerns about hospice that might be future barriers to seeking hospice care were varied, but the most identifiable concern, especially among younger patients, was the expected cost of hospice services. These results were forwarded to Peace Harbor Hospice to better help them address the concerns of the community and to identify local potential barriers to hospice care.

Views on Medicare Reform Bill from people who it affects most
Date of project: 11/10/2003

Over 35 million US seniors today rely on Medicare as their primary health insurance. These seniors have very few/no options for prescription drug coverage, and none of these options are part of a routine Medical benefit package. In an attempt to address this situation, this year the Medicare Prescription Drug Improvement and Modernization Act of 2003 was passed by the U.S. Congress. The intent of this bill was to offer seniors a limited drug benefit as well a competitive choices in health plans, a number of reimbursement increases for physicians, and many other changes to Medicare in general. The intent of my projects was twofold. My first objective was to determine how well the seniors understood this new legislation and what their general view of it was. Secondly, I wanted to determine the legislation's impact on the sample of elderly Medicare recipients from the Florence, OR family practice clinic where I worked. A phone and office interviews were conducted to examine these issues. The results indicated of an almost even 48% to 52% division in support for and against this reform, repectively. However, the understanding of the details of this legislation was lacking for a majoirty of seniors. It was also evident, that if the sample is representative of the Medicare recipient community in Florence, at least 40% will not see any relief in their current prescription medication costs.

Investigating the diabetic population of Florence, Oregon.
Date of project: 8/18/2003

As people age their risk of developing diabetes mellitus type II increases. Florence is a growing retirement community with a large population of individuals with diabetes. The long-term complications of diabetes can be very devastating to an individual. A survey of 18 diabetic patients was conducting to evaluate their knowledge about diabetes. This will show us if the education that they are receiving is effective and if they are retaining the knowledge. The patients will also rank their knowledge and this will be compared with the number of questions that they get correct on the survey to assess true knowledge vs. perceived knowledge. The survey showed that the perceived knowledge vs. true knowledge did not correlate well. The regression line for this data was 0.0392. Many participants did not know the complications of diabetes, the function of insulin, or what their blood sugar should be in the morning. The patients seemed to be losing a lot of the knowledge that they learned during their diabetes education classes. Integrating refreshing education courses could be beneficial to these patients.

Implementation of a group-based health care delivery model in Florence, OR: exploring a possible solution to this community’s increasing health care deficit
Date of project: 5/5/2003

The six Family Medicine doctors currently practicing in Florence, Oregon conceptually agree that there will not be enough space, money, or physicians within their present medical system to meet the growing healthcare needs of this growing rural community. All six physicians and their ancillary staff at Peace Harbor Health Associates (the only Family Medicine outpatient practice in Florence) recognize this increasing healthcare deficit, as well as the associated problems with regard to access, service, and quality of patient care that it creates. An innovative approach has been initiated by one of the physicians in an attempt to alleviate these specific concerns. This physician has recently implemented a group visit model to address the needs of his large diabetic patient population. This study surveyed the effectiveness and acceptance of the diabetic group based doctors visit model through interviews with the physician, ancillary staff, and patients involved in the first Diabetic Wellness Physician Group Appointment (DWPGA) program. Study results found that the DWPGA program was well received by all of the individuals involved. The physician, his staff and, perhaps, most importantly his patients were found to be very satisfied with their experience, with the vast majority of participants preferring the group-based setting to that of individual diabetes appointments.

Prostate Cancer in Florence: Listen to the Patients
Date of project: 5/5/2003

Prostate cancer is the most common non-skin cancer diagnosed in men and the second leading cause of cancer death. Each year, about 220,900 men will be diagnosed with prostate cancer, and 28,900 will die from it (1). Age is the biggest risk factor. In fact, more than seventy percent of all prostate cancers are diagnosed in men over age sixty-five (1). In 2002, 15% of the population of Florence was composed of men over age sixty-five (2). For this reason, prostate cancer is important to this town and to its physicians. Much information concerning the screening and treatment of prostate cancer is readily available in books and online, however, there is no substitute for patient experience. This project provides this opportunity by looking at prostate cancer from the patient’s perspective. Eighteen men with a history of prostate cancer, from the Health Associates of Peace Harbor Internal Medicine practice, were interviewed concerning their experience with the disease. The patients were asked about their screening, diagnosis, and treatment. They were further questioned concerning satisfaction with their treatment choice, side effects from treatment, and finally, if they had any advice for the newly diagnosed patient or the physician treating him. At the time of diagnosis, the men ranged between the ages of fifty-six and seventy-nine, and they had undergone a variety of different treatment options. Thirteen of the men had experienced significant treatment-associated side effects, and six had their cancer reoccur. From these differing experiences comes a rich opportunity for the physician to learn.

Strategies for Coping with Rising Medication Costs.
Date of project: 3/24/2003

Rising prescription medication costs pose an acute financial burden on the lives of rural Oregon's senior citizens. This project is designed assess patient difficulty and provider awareness with the issue and provide education materials. Short surveys were given to senior patients with questions concerning income, costs of medications, insurance coverage, compliance, and strategies used to lower costs. Additionally, to assess physician knowledge of cost issues, a quick, "off-the top-of-your-head" quiz concerning prices of three common medications at different doses. Focusing in on pill-splitting, an computerized chart review was used to identify potential savings from implementing pill-splitting techniques for one common medication. Finally, both patient and physician education handouts detailing cost saving strategies were developed and distributed, along with a common medication price list for providers.

Diabetes: Low Diabetic Follow-Up Rate in Florence, Oregon
Date of project: 3/24/2003

Having noted a low percentage of annual diabetic follow-up in Dr. Dodson’s practice (59% of 46 patients reported as not coming in for over a year), especially compared to other doctors in the same clinic, Dr. Dodson and I posed the question, “why aren’t his diabetic patients coming back to the clinic to be seen for their annual diabetic visit (termed DWAP--diabetic wellness assessment program--exam by this clinic)?” For my Florence, Oregon community project, I isolated Dr. Dodson’s diabetic patients, especially the ones noted by the diabetic counselor that hadn’t been seen for their DWAPs in over a year. I did a chart review on all of his diabetic patients and a phone interview with each of those without an annual DWAP regarding their reasons for failing to be seen. Surprisingly, I found that most of his patients actually had been seen by him for a DWAP in the last year, are currently seen by an endocrinologist for their diabetes, or are no longer under Dr. Dodson’s care. 3 patients he had performed equivalent testing for without equivalent documentation; 4 patients’ tardiness was due to inadequate clinic follow-up scheduling during an organizational transitional period, now resolved. The rest (only 5) had individual mitigating life circumstances. Only 1 patient seemed to truly be uninterested in aggressive follow-up, quite contrary to what we had expected. Therefore, the vast majority of Dr. Dodson’s patients have more than adequate diabetic follow-up, reflecting both his and Peacehealth’s commitment to diabetic health.

Type 2 Diabetes Mellitus in Florence, Oregon. The Cost of Disease Management
Date of project: 12/30/2002

Diabetes Mellitus is a disease marked by several pathophysiologic consequences including hyperglycemia and eventual end organ disease secondary to altered physiological states. Type 2 Diabetes (DM2) is manifest by insulin resistance leading to eventual impairment of insulin secretion by the pancreas and increased glucose production via gluconeogensis in the liver. The prevalence of DM 2 is rising in the US and is expected to continue to rise rapidly due to the occurrence of obesity and reduced activity levels. Oral hypoglycemic drugs are a major line of therapy in the treatment of DM 2. Many people diagnosed with this health challenge in Florence, Oregon are part of a population that might have limited assistance accessing drug therapies due to the limitations of traditional Medicare coverage. As many patients must contribute to or are completely responsible for the cost of medication and these drugs reduce long-term complications, the patients encumbered by this disease are in essence buying their long term health.

Dispelling the Myth about Acupuncture in Florence Oregon: A Patient Education Project
Date of project: 11/4/2002

In primary care, there are many medical conditions and nonspecific complaints for which patients present, but don’t find appropriate relief. For example, musculoskeletal pain is a complaint seen daily at the primary care clinic in Florence, Oregon. Many of these patients present multiple times, finding no respite with many different treatment modalities. Either the treatment options simply don’t work for them or the side effects are debilitating (i.e. drowsiness with muscle relaxants and narcotics). Further, many patients are looking for a non-invasive alternative to elective surgery (i.e. carpal tunnel). This project aims to increase knowledge about a lesser known treatment option—acupuncture—that could bring considerable benefit to these patients. The need for this was recognized after seeing dozens of patients who were not finding relief with traditional methods. Further, physicians who did mention acupuncture as a treatment option, were often met with unfamiliarity from their patients and time constraints prevented further education. Aside from these clinic observations, consult with local acupuncturists and clinical acupuncture observation was also done to help with the project. The result of the project is the creation of a patient education pamphlet about acupuncture. This pamphlet will increase awareness about acupuncture in general, its effectiveness for certain medical problems, and its availability in the community. The ultimate goal is to find relief for patients whose needs aren’t being met with traditional approaches.

Alternative Healthcare in Florence, Oregon
Date of project: 9/23/2002

Florence is a retirement community of about 7300 people, with many low income residents. There are a surprising number of alternative healthcare options in such a small and not wealthy town. This study sought to uncover the reasons behind the use of alternative healthcare in this population. Primary care providers at the only hospital in town were questioned about their practices surrounding alternative healthcare and their patients. Four commonly recommended herbs were glucosamine sulfate for joint pain/arthritis, red yeast rice for hyperlipidemia, saw palmetto for BPH and St. John's wort for depression. Their motive behind recommending these aligned with patients reasons for using them. The majority use supplements because they are significantly cheaper than prescription medications without precription coverage from insurance. Some use the supplements because their primary care provider suggested them, others to match their philosophy of life and healthcare. Several patients with chronic pain issues use alternative healthcare providers such as the acupuncturist, acupressurist or naturopath for treatment of a condition for which there are not good answers. These alternatives are important to the people of Florence as another option, be it to compensate for lack of insurance coverage or to match with their belief system. More research and information is needed, desired and on its way due to funding from NIH of several well designed trials.

Concerns about Hormone Replacement Therapy in Florence, Oregon: Development of an Educational Handout for Patients
Date of project: 8/12/2002

Hormone replacement therapy (HRT) has been prominently featured in recent television news broadcasts and newspaper articles, since one trial of an observational study - the Women’s Health Initiative - was stopped because the number of cases of breast cancer caused by hormone replacement therapy had exceeded acceptable safety limits. Always a difficult choice for women, HRT has become an increasingly complex treatment for both patients and physicians. Of the postmenopausal women in the United States, approximately 40%7 opt to use HRT for some length of time, though many women discontinue therapy within a few years of initiation. Because the Health Associates of Peace Harbor serves a primarily elderly population in Florence, Oregon, menopausal and postmenopausal women comprise a large part of clinic practice. Thus, HRT is a relevant and important topic to many of the female patients, whose concern regarding their possible increased risk of breast cancer and thromboembolic disease with use of HRT appears to have increased recently due to extensive media coverage. This project consists of use of observation and informal surveys to define a population - menopausal and post-menopausal women on HRT – and a need – accessible information on HRT. After consideration of the clinic’s use of informational handouts on other health topics, and the need for a form of education on HRT that is both efficient and easy to use, recent journal articles and online sources were used to create a double-sided, one-page educational patient handout.

Anticipating Longitudinal Growth
Date of project: 2/11/2002

This paper encompasses 3 related projects: first, to assess patient satisfaction with the process of establishing care with a PCP at Peace Harbor's Health Associates clinic in Florence, OR; second, to assess local FNP's perceptions of their professional relationships with their Physician colleagues & to describe some current literature on the topic; third, to assess the attitudes of employees of Health Associates about the quality of care delivered by Mid-levels as compared to Physicians. Such data could prove useful in planning for Peace Harbor's expansion. Three distinct surveys facilitated these goals. On average, new patients consider a (5) day wait "reasonable," but a 23-24 day wait "expected." In light of this, 44% of incoming patients had to wait "longer than expected." 83% of new patients feel the most important quality in selecting a specific PCP is his/her special interest in their disease, about 67% were assigned to their first-choice PCP, & 94% of incoming patients feel provider continuity is more important than not. The current FNP's feel their practice is an admixture of "collaborative" & "parallel" models. Finally, staff & nursing cohorts have overwhelming confidence in Physicians to provide superior primary care over Mid-levels (contrary to results of a randomized trial used as the survey's "answer key"), the Mid-level cohort holds false beliefs about their ability to provide better care than Physicians, & Physicians demonstrate uncertainty about the matter.

Mental Health Service in Florence, Oregon
Date of project: 3/25/2002

Throughout my limited interview sessions with the mental health providers, I was repeatedly reminded of the superior mental health coverage in Lane County. Unfortunately, I have not obtained data to support this claim in quantifiable terms. Instead, this project aims to highlight the two agencies that provide mental health services to Florence: namely, the Siuslaw Pacific Center and Peace Health Counseling Services. More importantly, while I attempt to demonstrate how these two agencies function as an integral part of mental health provision in Florence, I would also highlight the differences between the two such that they work in complementary ways.

Screening For Colorectal Cancer At Health Associates Of Peace Harbor In Florence, Oregon.
Date of project: 1/2/2002

Colorectal cancer is a common cause of cancer related death that can often be prevented by routine screening. The aim of this study is to determine the proportion of patients of Family Physicians at Health Associates of Peace Harbor that have been screened for colorectal cancer, as well as to identify potential barriers to colorectal cancer screening specific to this clinic. The electronic medical records of 100 clinic patients over the age of 50 were reviewed for documentation of colorectal cancer screening, and the type of screening was recorded. Additionally, four family practice physicians were interviewed to identify potential barriers to colorectal cancer screening. Of the 100 medical records reviewed, 38 had received some form of screening (16 colonoscopy, 6 fecal occult blood tests, 15 sigmoidoscopy and 1 dual contrast barium enema). The major barriers to colorectal cancer screening identified by physicians were public awareness and acceptance of colorectal cancer screening and time constraints during patient visits. Additionally, all physicians felt that having a "Health Maintenance" section of the medical record would be helpful. The proportion of patients being screened at this clinic was comparable to national survey data showing that 44% have been screened. Specific recommendations to improve colorectal cancer screening rates are to introduce a "Health Maintenance" section of the medical record which documents recommended and performed screening tests for each patient, and to use this database to send patients information about recommended screening tests prior to complete physical exams.

Preventative Care And Management Of Risk Factors In Elderly Patients With COPD In Florence, OR
Date of project: 1/2/2002

In the United States, COPD is the fourth leading cause of death. This retrospective study sought to examine preventative care practices and management of risk factors in elderly patients with COPD from the internal medicine clinic at Health Associates of Peace Harbor in Florence, Oregon. Endpoints examined included prevalence of smoking, annual influenza vaccination, and diagnosed depression. 21% of patients in this study were current smokers, and almost all had documented evidence of being advised to quit by their physician. 23% had received an annual influenza vaccination. 14% of patients had been diagnosed with depression, and almost all had documented evidence of treatment with pharmacologic therapy. This report discusses the need for development of improved comprehensive care for elderly patients with COPD and offers specific suggestions, including utilization of numerous community resources as a way to facilitate patient participation and development of a therapeutic alliance.

The Impact of Patient Education on Routine Screening of Common Treatable Ocular Diseases in the Elderly Population of Florence, Oregon.
Date of project: 5/6/2002

This project was designed to achieve two goals: 1. To estimate the adequacy of routine screening of several common treatable eye diseases (cataracts, glaucoma, and macular degeneration) in the elderly population in Florence, Oregon. 2. To educate this subset of the population on the importance of such preventative care in order to increase the percentage of those receiving adequate screening. The project is a study in which the subjects were given a 20-minute interactive lecture on the topics of cataracts, glaucoma, and macular degeneration and then given a questionnaire. Of the people surveyed, 32.26% were not receiving adequate screening for cataracts, glaucoma, and macular degeneration. However, of this group that was receiving inadequate preventative care, 60% reported that they were more likely to seek such care as a direct result of the lecture. In addition, 96.77% of all the subjects reported that they felt the lecture was beneficial to their understanding of the eye disorders discussed, and as a result, 83.87% stated that they were more likely to continue to receive or seek out preventative eye care as a result of the lecture. These results suggest that there is a significant percentage of the elderly population in Florence, Oregon who are not receiving adequate preventive eye care and that this percentage may be decreased through a community education program.

Osteoporosis Prevention: Educating Patient Educators
Date of project: 5/6/2002

There is ample data available as to the epidemiology of osteoporosis, its relationship with patient morbidity and mortality. There is also evidence that as a Caucasian retirement community with a long, dark winter, the Florence community represents a population at particular risk of suffering from osteoporosis. Given the short period of time available to promote change in the community health practices, the most effective method is education of the health care providers. This community-based project sought to educate health care providers as to the practical aspects of osteoporosis risks, consequences and prevention. An educational talk about osteoporosis prevention was held for the Medical Assistant staff at Peace Harbor Health Clinic. The responsibilities of the MA staff include scheduling appointments, giving patient advice both in the clinic and over the telephone, eliciting a basic patient history, taking vital signs and promoting basic health with appropriate educational health interventions. Clearly, this is a population of health care providers with a great deal of patient contact who may benefit from further education in preventative health. To evaluate the effectiveness of the presentation in providing helpful information to the MA staff an educational survey and quiz was given before and again after the presentation. In addition, a short questionnaire as the educational value and effectiveness in encourage preventative measures was also given. Final evaluation revealed one hundred percent of the 18 persons who filled out their surveys showed improvement after the presentation. (Appendix C). The average survey improved by 2.4 correct answers out of 7 possible correct answers. The initial average of the survey was 55% with a final average after the presentation of 90%. This represents an improvement rate of 35%. The results of this community project indicate that the content of the talk was appropriate for this audience. The initial scores before the talk indicate that much of this material was new or unfamiliar to the staff. In addition, the scores consistently improved indicating the talk was appropriate and beneficial. Further, only one participant failed to indicate that this talk was helpful to further her understanding and increased the likelihood she would encourage patient preventative health in regards to osteoporosis. Audience participation was also high and, although not reflected in the numbers, is also a potential indicator of interest and the potential to instigate change.

Staying Active and Correlates to Geriatric Depression in Florence.
Date of project: 9/24/2001

An attempt was made to understand the nature of geriatric depression in a small coastal town in Oregon. The study was originally formulated with the hypothesis that a casusal link exists between lack of meaningful social activity and depression. Patients 65 years and older that have been diagnosed at one time with depression were selected from among the patients of a local internal medicine physician. These patients were interviewed in depth about their present and past level of involvement in social activities, limitations on participation in activities, degree of social isolation, living situation, palliative/aggravating factors, and use of antidepressant medications. Following the interviews, the link between level of activity and depression was found to be complex. As a supplement to the study, a detailed list was compiled of area services for seniors, meal programs, interest and support groups, social activities, and volunteer opportunities. This information was organized into a pamphlet, which was mailed to those participants that indicated interest. It was also made available to staff in the physician's office and to discharge planners at the local hospital.

Availability Of Abortion Services: Rocking The Boat In A Small Oregon Coastal Community.
Date of project: 9/24/2001

This study examined the availability of abortion services in a rural Oregon coastal community in October 2001. All family practice and internal medicine providers were surveyed on their current practices of abortion counseling, referral, and provision. Seventy-five percent of the questionnaires were returned, with 78% of providers stating they see women of childbearing age. Of these providers, none would ever include discussion about abortion as a form of contraception with their patients, and only 57% would always discuss abortion as an option in an unwanted pregnancy situation. Furthermore, 14% of providers stated they would neither provide an abortion nor a referral for an abortion if they were specifically asked for these services. It is apparent from these results that abortion services are challenging to procure in this small community

Prevalence of Pneumococcal Vaccination; Among Diabetic Adults Served By The Health Associates Of Peace Harbor In Florence, Oregon.
Date of project: 8/13/2001

Streptococcus pneumoniae (pneumococcus) is a bacterial pathogen that colonizes the upper respiratory tract and causes serious morbidity and mortality worldwide. Diabetics, although not more susceptible to the development of pneumococcal infection, are more likely to become bacteremic and require hospitalization than are non-diabetic persons. Furthermore, diabetics hospitalized with community-acquired pneumonia are more likely to die from the infection than are non-diabetic patients. Fortunately pneumococcal vaccination can reduce the occurrence of invasive pneumococcal disease and the associated morbidity and mortality. This community-based project was designed to assess the prevalence of pneumococcal vaccination among diabetic adults served by the Health Associates of Peace Harbor primary care clinic in Florence, Oregon as well as to determine the prevalence of pneumococcal vaccination among diabetic adults discharged from Peace Harbor Hospital, during a one-year period, with a diagnosis of bacterial pneumonia. Approximately 37% of sample diabetic patients at the Health Associates of Peace Harbor primary care clinic had received the pneumococcal vaccine. Diabetics 65 years of age or older were more likely (46%) to be vaccinated than those younger than 65 (26%). Fifty percent of diabetic patients discharged from Peace Harbor Hospital with a diagnosis of bacterial pneumonia had received the pneumococcal vaccine prior to admission. Those not vaccinated prior to admission had an average of 19 clinic and 2 emergency department (ED) visits in the 36 months prior to admission. The results of this community project indicate that the Health Associates of Peace Harbor primary care clinic would benefit from adopting the Healthy People 2010 objectives for pneumococcal vaccination of diabetics. Several strategies can be implemented to increase pneumococcal vaccination among diabetic adults including advocating more precise documentation standards, educating diabetic patients about the risk of pneumococcal disease, minimizing missed clinic vaccination opportunities and taking advantage of a wide variety of vaccination opportunities outside of the clinic.

Access To A Creative Solution: The Siuslaw Plan: Are Clinic And Emergency Department Personnel Doing Their Part?
Date of project: 7/2/2001

The purpose of this project is two fold, to describe the Siuslaw Plan, a creative attempt to increase health care access by the growing uninsured population, and to assess the degree of active participation by the Florence, OR Peace Health primary care clinic and emergency department personnel in facilitating access to this plan. The Siuslaw Plan is a local charity program specific to the Peace Health organization targeting residents of Florence, OR and surrounding communities who do not have health insurance, yet have an income that disqualifies them for the Oregon Health Plan. Access to such a plan can be greatly facilitated by a knowledgeable staff. Staff directly involved in outpatient interaction and care was interviewed to assess awareness of and referral to the Siuslaw plan. 100% of Doctors and Nurse Practitioners were familiar with the Siuslaw Plan, the highest group interviewed. The percentage of doctors and nurse practitioners that knew the eligibility criteria and actively participated in referring a patient to the Plan was consistently higher than the nursing staff and other support staff. The Outpatient clinic staff consistently outperformed the Emergency Department staff in all aspects studied.

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