RCHC Community Project Abstracts

Back to subject search page or search by preceptor site Access to Specialty Care Services in Curry County Project Date: 10/12/2009 The limited availability of local specialty care services in Gold Beach, Port Orford, and Brookings, Oregon is a significant barrier to accessing adequate health care for patients in Curry County. Patients frequently have to travel to other cities in order to obtain necessary care, incurring additional costs related to transportation/travel, lost work hours, childcare, and direct health care costs. This project aims to illustrate potential barriers to accessing care, delineate where providers are currently referring patients for specialist services, and quantify the costs (time and monetary) of travel for the purpose of accessing such services. Demonstrating the challenges associated with utilizing specialty care services as they currently exist provides insights into potential solutions for addressing these issues in Curry County. The Strawberry Wilderness Community Clinic: A Patient Centered Medical Home for the people of Grant County? Project Date: 10/12/2009 The Patient Centered Medical Home (PCMH) is a model of care gaining support in the primary care community as a delivery system focused on coordinated, comprehensive health care and the patient experience. As health care reform in this country pushes to make improvements in quality and safety, the PCMH may become an ever-more-relevant piece of the healthcare puzzle. However, transitioning to this model from the current fee-for-service model requires time, money, and a coordinated effort by all levels of staff to change some of the fundamental pieces of the health care delivery system. Is this transition feasible in a small, rural practice like the Strawberry Wilderness Community Clinic (SWCC) in John Day, Oregon? How well does SWCC already provide a PCMH for its patients? What are some of the barriers that SWCC (and presumably other small rural health clinics) face in providing this type of health care and what are some ways in which SWCC can move toward providing a PCMH in the future? This study attempted to address these questions via interviews with clinic staff along with a survey developed to assess patient satisfaction. Results of the interviews were qualitative in nature and produced information regarding quality measures, information technology and practice organization at the SWCC. The patient survey generated 25 responses, producing quantitative information on the patient experience and access to healthcare. It was determined that SWCC provides some aspects of a PCMH, mostly with regards to the patient experience, but struggled to meet most of the quality measures associated with providing a PCMH. The biggest barrier appeared to be a lack of trained staff to do data collection or analysis on the quality of health care and health outcomes at SWCC. There were many suggestions for future improvement. Analysis of mental health disorders at Dunes Family Health Care, in Reedsport, OR. Project Date: 10/12/2009 Background: Studies show that primary care physicians in rural communities have to play a larger role in mental health care when compared to urban physicians. This is due to the fact that in many rural communities primary care clinics are the only accessible mental health resource for much of the population. There are many that believe that primary care physicians lack the training, skills, and time necessary to shoulder this larger burden. Introduction: The goal of this project was to determine at what frequencies mental illnesses are seen in clinic at Dunes Family Health Care in Reedsport, OR; what the demographics of these patients are; and what treatments are commonly implemented. It was hoped that this data would be valuable to Dunes Family Health Care clinicians as it could be used to better help allocate the clinics’ mental health resources in the future. Methods: Using the clinic’s electronic database, lists of patients with the most common mental illnesses were attained using the corresponding ICD9 codes. Records were pulled from the 2008 calendar year. Random charts were selected from the lists and reviewed on the basis of age at the time of visit in 2008, gender, number of visits for this problem in 2008, new problem in 2008 or follow up, and common treatments. Results: A total of 191 individual patients were identified using the diagnostic codes which accounted for an estimated 15.5% of the total patients seen in 2008. Depression was the most common diagnostic category with 38.8% of the diagnoses. Close behind was Anxiety with 31%. Next was ADHD with 16%, followed by Bipolar disorder and Dementia both with about 6%. PTSD had 2.5%. Schizophrenic disorders yielded 0%. Discussion: Much of the data correlates well with prior studies, specifically with regard to depression and anxiety data, including type and frequencies of medication regimens. Unfortunately, this study had significant limitations. The sample size was not very large for many of the categories which significantly reduces our ability to trust that the data is representative of the population in question. This was likely due, in part, to the fact that ICD9 codes were many times not recorded for a variety of reasons. Also, ICD9 codes may not be the best tool for this type of analysis because patients are often given the wrong code. Meeting the Need: Is the Pediatric population in Coos County adequately covered by the medical community? Project Date: 8/3/2009 There are eight pediatricians in Coos County serving the Coos Bay and North Bend communities. They meet regularly to address current and emerging concerns to their patient population. At a recent meeting, it became apparent that the current coverage for the pediatric community was unknown. This analysis seeks to reveal more information about the pediatric population in Coos County, including the population of the pediatric community, the number who receive at least annual care, and the principle means of payment for healthcare received. The data was collected using US Census information, collaboration with the two pediatric clinics, and with data from the catchment clinic in the county. This data indicates that no more than 55% of the pediatric population sees a pediatrician, and less than 60% receive care either from a school based clinic, a catchment clinic, or the pediatricians. Available resources for patients with mental health concerns Project Date: 3/16/2009 Mental health issues, depression and anxiety in particular, are a concern common to urban and rural populations alike. Due to the generalized scarcity of resources often found in rural and frontier settings, access to care is a major concern given difficulties with both maintaining appropriate mental health services as well as the limited ability for patients to afford them given high rates of poverty and lack of insurance. By interviewing medical and mental health providers in Coos Bay and North Bend, this project seeks to identify available resources for patients with mental health concerns and qualitatively assess how well these are being utilized by the healthcare community. Current use and capacity for colorectal screening by colonoscopy in Grant County, Oregon Project Date: 3/16/2009 Colorectal cancer incidence and death is largely preventable by screening. Colonoscopy is a particularly compelling screening modality for frontier communities, but capacity may not exist in all these communities to increase screening via colonoscopy given limited access to resources and physicians. A study was conducted in the frontier communities of Grant County, Oregon to determine existing colonoscopy uptake rakes and screening capacity. Addressing Mental Health Care Needs in Clatsop County: The Impact of Inadequate Acute Crisis Management and Lack of a Safe Room Project Date: 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. A Long Road Ahead: Barriers for the transition to a patient-centered medical home model of care in the rural setting Project Date: 2/9/2009 The “medical home” concept has emerged in recent years as a potential solution to make quality health care more affordable and accessible. It is defined as a patient-centered team effort to provide comprehensive and coordinated care over a sufficient duration of time to foster a strong level of patient-physician understanding and trust. The literature has demonstrated that this model has the ability to improve quality, reduce errors, and increase both patient and physician satisfaction. The team is a fluid network of health care professionals whose composition changes over time to meet the patient’s changing needs, with the primary care physician always operating as the team leader. The patient-centered medical home (PCMH) model also involves payment reform that compensates primary care physicians for productivity that has previously gone undercompensated, all while containing overall health costs. For small practices without pre-existing technologic or staffing infrastructure, the transition to a PCMH identity may by overwhelming or even seemingly insurmountable due to the potential for decreased productivity, financial strain, and personnel shortages. While working in the Tillamook, OR community, I investigated some of the barriers that a particular practice, Bay Ocean Medical, or others like it, might encounter should they opt to acquire that designation. The Rural Elderly: A difficult to manage health care system? Project Date: 2/9/2009 •61 million people live in the rural U.S. and 15 % of them are 65 years of age or older. When it comes to healthcare, the shortages have even greater implications for these rural elderly. So, it is the goal of my project to examine how rural elderly manage their healthcare. By using the current literature and interviews of patients and doctors, I have set out to understand if the rural elderly in Hood River find it difficult to manage their healthcare and to provide suggestions for improvements that all healthcare providers can use. Access to Health Care in Rural Communities Project Date: 2/9/2009 Access to health care in rural communities has long been recognized as a public health concern and much effort has been expended to study and remedy the problems with access to healthcare in these areas. In our study we examine access to healthcare, and quality of health care for health care providers in four communities in the mid-Willamette Valley in Oregon. All MD’s, DO’s, NP’s, and PA’s in the communities of Stayton, Sublimity, Aumsville, and Mill City OR were surveyed anonymously about their access to healthcare and whether they receive the screenings recommended by the US Preventative Services Task Force (USPSTF). Twenty seven providers where surveyed and 21 responded. Of these, 75% had a personal PCP, but less than half have had a physical exam in the last 2 years and 3 had never had a physical exam. Only 62% of USPSTF screenings were complete for this group and over half of these were self screenings. Trauma Management at the Cottage Grove ED: Change in Process Project Date: 2/9/2009 Trauma preparedness in small community hospitals remains a Catch-22. On the one hand, these hospitals may not be designated formally as a trauma center – any organized emergency response units recognizing a serious trauma would bypass these hospitals and take the patient to a larger center. On the other hand, the community at large may at any moment arrive with serious trauma, unaware of the specific capabilities of their nearest hospital. Thus, these hospitals must be as prepared for trauma as possible despite often limited resources. Cottage Grove Community Hospital is one such hospital, located in a small town of 9,000 in Cottage Grove, OR. Last year a trauma event that was not handled optimally initiated a major revamping of the hospital’s trauma-preparedness on many levels. This project is aimed at outlining and understanding the process of change thus far, primarily via several discussions with the Emergency Department operations manager, Naomi Grace. Both the process of review of the event as well as the specific modifications made thus far were described in detail. Lastly, Ms. Grace indicated that her next step was to be a literature review of rural trauma. The final contribution of this project was the completion of a literature review and presentation of those findings to her. Acute Psychiatric Care for the Underserved Population of Ontario, OR Project Date: 2/9/2009 There is an increasing demand for psychiatric care and a decreasing supply of corresponding resources in rural Oregon, including communities like Ontario and greater Malheur County. Although availability and access to psychiatric care is a problem throughout the United States, significant obstacles exist in rural areas that create unique issues that are not easily overcome. Specifically, while primary care physicians serve to treat common mental health conditions such as anxiety and depression as part of their daily practices, specialty care needed to treat more complicated mental health cases and acute psychiatric crises are becoming increasingly scarce. In the case of the emergency room, hospital staff must overcome a number of hurdles when assessing, evaluating and referring every single psychiatric patient. This is especially evident at the Holy Rosary Medical Center (HRMC) hospital in Ontario, Oregon, where numerous factors combine to make treatment for the acutely mentally ill frustrating at best and impossible at worst. The goal of this project was to: 1) formally investigate these problems and complications; 2) discuss the barriers as they exist in their current state; and 3) suggest some reasonable recommendations that could be implemented to improve present conditions. Profile of First Responder Program in Harney County Project Date: 2/9/2009 Harney County Emergency Medical Services face unique challenges in providing emergency care to the remote areas of the Oregon’s largest and least densely populated county. The implementation of an all-volunteer First Responder Program around the county permits trained citizens to arrive on the scene sooner than EMS crews and begin to provide care to the patient and information to the crew en route. A profile and critical review of the First Responder Program demonstrates the importance and inherent challenges of maintaining this program that plays an integral role in providing emergency services in rural and frontier regions. Assessment of Barriers To Hospice Referral In Baker City, Oregon Project Date: 2/9/2009 Hospice services have long been recognized as an important component in the spectrum of healthcare but certain barriers to referral still exist. This study attempted to assess potential barriers to referral in Baker City, Oregon by looking at perceptions, attitudes, and knowledge of hospice services by local primary care providers. Initial information was gathered through personal interviews with patients, hospice workers and physicians. The results of the interviews were that referral habits likely varied by age and experience of the physician, with older physicians being less likely to refer. Similarly, a lack of knowledge was thought to inhibit referral. An anonymous survey was then collected from 6 out of the 9 primary care physicians in town which assessed attitude, knowledge, perceived benefits and perceived barriers to referral. The results showed that every physician surveyed had a high level of knowledge about hospice services and requirements and that this did not likely affect referral rate. There was consistency between local opinion and what was found regarding age of physician with the one responding senior physician being less likely to refer. This was determined to be likely due to a poor interaction history between the physician and local hospice services. Additional responses from the other senior physicians in town could not be obtained, so no generalizations could not be made. However, it was evident that the greater factor that influences many aspects of small town life is determined by how well people work together. Implementation of Personal Health Records in a Rural Community Project Date: 12/29/2008 The term "patient-centered care" is an often-used catch phrase in family medicine. This approach includes core values such as information sharing, participation and collaboration. Stemming from these ideas, interest in the development of personal health records (PHR's) has been a recent hot topic in the world of Health Information Technology. PHR's are a patient-directed tool that may help to deliver integrated, portable, interoperable, patient-centered care. They have many projected benefits especially in rural communities. These benefits include reaching out to areas of unmet need, helping to protect isolated communities, empowering patients and enlarging the "virtual" healthcare network. However, significant risks and barriers to implementation exist and these must be further defined, analyzed and accounted for before PHR's can become a reality. As such, with this project I sought to develop a thorough understanding of OHR's and analyze the risks, benefits and barriers to implementation in a rural community. Overall, PHR's have many potential benefits but implementation will require overcoming many barriers (financial, logistical, and technical) and carry significant security risks to all parties involved. Recruitment and Retention of Physicians in Klamath Falls, Oregon Project Date: 12/29/2008 Recruitment and retention of physicians in rural communities continues to be a problem throughout the United States. This study aimed to characterize the unique challenges and solutions to the problem of physician recruitment and retention faced by the larger rural community of Klamath Falls, Oregon. Due to its status as a large rural community, Klamath Falls is not eligible for many of the state and federal government programs that have helped smaller rural communities recruit physicians, such as loan repayment programs. This study identified three areas of concern when it came to recruiting new physicians: frequent on-call duties, poor reimbursement rates due to large Medicare population, and lack of loan repayment programs. Through interviews with physicians, citizens, and business members possible solutions to these barriers were discussed. Future direction for this project would entail identifying strategies and resources to aid in overcoming the barriers of retention and recruitment of physicians. Uncontrolled Diabetes in the Hispanic Community of Hood River, Oregon: Identifying Barriers to Good Diabetic Control Project Date: 10/13/2008 It is a well known fact that diabetes is one of the leading chronic diseases in our country today. However, it is not well known why some minorities have a higher risk to acquire this disorder. Compared with Caucasians, blacks have a 60 percent higher risk of developing diabetes, and Hispanics have a 90 percent increased risk. These numbers are astonishing. Now let us narrow our focus to the Hispanic group. Why is it that Hispanics are at higher risk? And why do they have higher rates of uncontrolled diabetes and less continuity of care for their diabetes in general? These are some of the questions that this brief study will attempt to answer. It will focus more on some of the barriers and problems faced by diabetic patients that receive their health care at La Clinica del Carino in Hood River, Oregon. Will Baker City Lose Its Only Nursing Facility? An analysis of the St. Elizabeth Care Center Project Date: 10/13/2008 The St. Elizabeth Care Center is the only Nursing Facility in Baker City, OR. The Care Center serves a population of approximately 16,000 residents in Baker County, a disproportionately large percentage of which are senior citizens. When it was discovered that the Care Center faced a fiscal crisis that threatened its closure, an investigation was made into the impact this closure would have on the community’s seniors. Consensus input from those involved in long-term care in Baker suggested that closure would constitute the loss of a critical resource. A further investigation was made into the causes of the Care Center’s financial instability and changes were suggested to prevent closure. Assessment of the Mental Health Resources in Milton-Freewater, OR Project Date: 10/13/2008 There is a universal need for mental health services in all areas of rural Oregon, including communities like Milton-Freewater. Additionally, there is an appreciable discrepancy between the services that are available for those who have private insurance, those who use state or federal plans such as OHP and Medicare/ Medicaid and those who have no health coverage. While this may be true for both urban and rural communities alike, there are other additional obstacles more unique to a rural area. Also, some of the mental health care can be provided by local primary care practitioners, however, they often lack the time and the specialized knowledge necessary for anything but maintaining patients that are already stable and in good control of their disease. Additionally, in a rural setting where social workers are not readily accessible, making it more difficult for physicians to know the local resources available in order to effectively help their patients. It was a general consensus from those interviewed for this project that the mental health resources of Milton-Freewater are lacking in many ways; however, there are still some very important services to be used. The goal of this project is to show both what resources are and are not available with the hope that those resources that still exist will be more effectively used. Access to Orthopedic Services in Cottage Grove, Oregon Project Date: 8/4/2008 Access to health care services meets many barriers in rural communities and the experiences of community members in South Lane and North Douglas Counties are no exception. While Cottage Grove Community Hospital is generally successful in meeting its community’s primary care needs, the availability of specialty services continues to be lacking. Through observation, interviews of patients and the medical community, and data compilation, the need for orthopedic services in Cottage Grove, Oregon, was assessed. Based on the data and observations, it can be concluded that Cottage Grove Community Hospital patients face significant obstacles to receiving orthopedic care. Furthermore, it can be suggested that there is sufficient patient demand for orthopedic services for CGCH to consider bringing orthopedic services to the facility. It is hoped that this assessment will raise the awareness of specific barriers to health care and provide a direction in which to work to minimize the obstacles Cottage Grove Community Hospital staff and patients face in providing and receiving specialty care, specifically orthopedics. Resources Available for Patients with Dementia in Columbia County, Oregon Project Date: 3/17/2008 Dementia represents a major health issue for geriatric patients in the United States. This study serves primarily as a community profile and assessment of the resources available to patients with dementia, specifically Alzheimer's disease and their families in Columbia County, Oregon. The study evolved during preliminary conversations with the staff of the primary care internal medicine clinic in St. Helens, Oregon. They identified the availability of resources for dementia as a consistent challenge in offering guidance to their patients. A survey of local resources was conducted which included site visits to nursing homes and senior centers, contacts with social workers, and internet searches for resources. The local resources were compared with those described in the medical literature and the National Alzheimer's Association. Questions to evaluate the effectiveness of the local resources were prepared for patients with dementia and their caregivers. A simple handout was prepared to identify key resources in the community and at large. Access to Mental Health Resources in the Astoria Area, A Narrative Survey. Project Date: 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. Cardiovascular Risk Reduction in Hood River, OR: Availability without Access Project Date: 2/11/2008 Although preventable, heart disease remains the number one cause of death in the United States. This study sought to examine cardiovascular risk reduction in an internal medicine clinic in Hood River, OR. Methods included observation of clinic practices, interviews with health care providers, and analysis of inpatient admissions for 2007. Patient education for cardiovascular disease in the clinic included brief, informal counseling performed during the visit and focused on risks that were identified through the patient’s history, physical examination, and laboratory evaluation. No handouts for patients were in use to augment this education or encourage lifestyle modification. A comprehensive cardiovascular risk reduction program was available but expensive, minimizing its utilization. The ultimate goal of this project was to create an efficient and educational patient handout aimed at increasing awareness of modifiable cardiovascular risk factors, encouraging lifestyle modifications, increasing patient-physician dialogue, and highlighting free or insurance-reimbursed programs available in the area. A Study of Specialty Referral Patterns from Scappoose Family Practice Project Date: 12/31/2007 Patients are referred from Scappoose Family Medicine Clinic to specialty practices which are usually located in Portland, 20 miles away. Accessibility to specialists and coordinating care with specialists for patients is cumbersome and time consuming. This study was undertaken to help determine feasibility for a specialist to visit Scappoose clinic at a reasonable frequency. Referral information was collected from the business office of the clinic. The study determined that orthopedics surgery was the most referred specialty with 6 patient referrals per week and physical therapy (PT) was the most referred service also with 6 patients per week. While PT is well supported in Scappoose, a weekly orthopedic clinic would better serve the needs of the community. However, a pre-requisite for a viable orthopedic clinic, with quick turnaround, is an onsite x-ray facility. No data exists that indicates the number of x-ray images that are ordered by the providers at the Scappoose clinic. To support the volume of patients, about 350 – 400 patients per week, it is certainly feasible to have an x-ray machine. A Summary of Continued Medical Education in Rural Health Care Project Date: 8/6/2007 Stayton, Oregon is a unique rural community due to its close proximity to the more urbanized population of Salem. Despite it's location, Stayton has established itself as a self-sustaining center of health care. The local 40 bed Santiam Memorial Hospital serves over 30,000 people with services including an emergency room, two operating rooms, a labor and delivery ward, laboratory services, and imaging services that include ultrasound, MRI, CT, and X-ray. There are no subspecialty units located within the hospital, however many specialists from Salem will travel to Stayton to manage a clinic one or two days per week. Because of these services, few local residents have to travel outside city limits to meet their health care needs. Despite the medical diversity of this small town, Stayton has few opportunities of continued medical education (CME) for its local physicians. The Impact of the recreational tourist on the Hood River ED Project Date: 8/6/2007 Hood River Oregon is situated in the heart of the Columbia River Gorge. It is surrounded by tall mountainous volcanoes, rivers, the mighty and windy Columbia, and miles of orchards and forested trails. Due to this setting, Hood River attracts sports enthusiasts from around the globe. Visitors come from Europe, Southeast Asia, Australia, South America, and nearby United States towns to enjoy this playground. While Hood River is only sixty miles from Portland Oregon, it is still considered a “critical Access area” in terms of medical care. The main hospital is owned and run by the Providence Medical system. The hospital only has twenty four inpatient beds including the ICU, and an eight bed emergency department. This area is facing a great deal of financial and medical difficulty as the closest medical neighbor in the Dalles, faces potential closure. Hood River has a population of five thousand. This number fluctuates seasonally with the summer winds and winter snow. Overall, the full time residents remain near a population of five thousand. This project was intended to investigate a small piece of this access problem. What is the impact of the visiting “recreational tourists” on a small town emergency department? General Surgery & Lower Umpqua Hospital: A Case Study and Perspective of Surgery in Rural America Project Date: 8/6/2007 The presence of a general surgeon is essential for health care in rural communities. Across America many rural communities and hospitals are underserved in terms of general surgery coverage. Lower Umpqua Hospital (LUH) in Reedsport, Oregon has experienced this shortage of rural surgeons first hand. Six years ago, LUH lost its first full-time surgeon. Since that time, LUH has had two additional general surgeons come and go, with the last leaving in March 2007. At times when the hospital has found itself without a surgeon it has turned to locums tenens for surgical coverage. Locums tenens surgeons change as frequently as once a month, significantly interrupting continuity of care and communication between the patient, surgeon and primary care provider. LUH is dependent on its surgical productivity for income and for keeping surgical patients within the rural health care system. This project investigated how surgical productivity varies when LUH has a full-time general surgeon versus locums tenens coverage and found that when LUH loses a surgeon, and must turn to locums tenens for surgical coverage, surgical productivity decreases considerably. This loss in surgical productivity has significant and far reaching effects on LUH, the community of Reedsport and the primary care providers of Dunes Family Health Care. Evaluation of the Potential for Expanded Use of the Cascade’s East Family Practice Residency Program Mobile Health Clinic Project Date: 7/2/2007 Southern Oregon includes much vast and scarcely populated territory. This is particularly true in the region served by the medical providers in Klamath Falls. Healthcare resources are intensely focused in Klamath Falls itself, with very minimal services available in the rest of the territory which encompasses almost 10,000 square miles. In addition to the geography, there are social and economic considerations which further pose barriers to effective healthcare access for the most rural residents. The Cascade’s East Family Practice Residency Program has initiated a mobile clinic in an effort to reach out to the vulnerable and underserved populations in the area. Currently the well equipped vehicle is targeting its service delivery to the homeless populations with monthly visits to the area shelters. Given the success of these initial efforts, there is great potential for successfully meeting further needs by expanding the services of the mobile clinic. A needs assessment was conducting to identify and prioritize potential uses of the mobile unit. The demographic and health data for the region was reviewed as well as the current health services. A list of needs and potential mobile clinic activities was then developed. Finally, the available resources and potential funding sources were evaluated and recommendations were developed for next steps. Physician Shortage: Who Will Bear the Burden? Project Date: 4/30/2007 A primary care physician shortage currently affects or is predicted to affect America. While much-deserved, growing attention is being directed at populations who are unable to access medical care because they lack medical insurance, this study attempted to support an observation that certain subsets of the medically insured population would bear a growingly disproportionate burden of the predicted physician shortage, despite medical insurance. The subset of the medically insured population studied was Medicare patients. The study design consisted of primary and secondary data collection in the form of physician surveys and population demographics. Data collected touched on both the deficiency of health care coverage in rural counties, and perhaps more importantly, the flux of disparity in access to this precious and increasingly limited commodity. Data collected clearly revealed a present access inequality in Douglas County and Roseburg, Oregon. Data also revealed that access to primary health care was reduced even among the medically insured population, specifically Medicare patients. Analysis of this data further demonstrated that three explanations were readily available for the growing disparity in access to care between the general insured population and Medicare patients: diminished rates of reimbursement; increased medical complexity; and demographic shift. Interpretation of this data would suggest that the predicted primary physician shortage would only aggravate this disproportionate burden already borne by the underserved and now by Medicare patients. Does Astoria Have A Physician Shortage? Project Date: 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. Interfacility transfers from Harney District Hospital, Burns, OR Project Date: 4/30/2007 Harney District Hospital (HDH) is the lone health care center for the 7,600 people living in Harney County, the largest county in all of Oregon. They are able to handle most every medical and surgical problem; however, as a small hospital with limited resources, certain patients come through that require transfer to a tertiary care facility for additional care. The hospital’s ambulance service conducts these interfacility transports; however, they are never quite sure what type of patient to expect when they back their ambulance in. This uncertainty makes it difficult to train and educate ambulance crews, arrange crew configurations, and equip and supply the ambulances. Similar ambiguity exists for the hospital as well. This study aims to elucidate what patient problems require transfer to other facilities, from which setting they are transferred, and by which mode of transportation. Data on every patient which required interfacility transport between December 2005 and April 2007 were collected from hospital databases, and analyzed categorically. During the study period, HDH transferred 3.5% of their patients. The majority of these 171 patients were transferred by ambulance; however, a full 1/3 of patients were transported by air. 50% of all patient transfers were for patients with cardiac, orthopedic, or surgical problems: a large fraction of acute issues. Some problems, like psychiatric, infectious, and oncologic were rarely transferred out. Proportionally, more patients from the inpatient ward required transport than from the ED; however, any given transfer was equally likely to have originated from either setting. These data will hopefully help county EMS to focus education on the high yield and rare maladies, appreciate how to efficiently equip and supply ambulances, and balance the skill level of crewmembers with the anticipated acuity of patients. The hospital may also find valuable information in this project, elucidating where additional specialist care, equipment, and education may decrease the necessity of some transfers, allowing more patients to receive definitive care within their community. Barriers to Accessing Dental Care and Use of Medical System for Oral Health Problems by Low-income Residents in Jefferson County, Oregon. Project Date: 4/30/2007 Despite the preventable nature of most oral disease, Oregonians have high rates of caries and periodontal disease. Low-income populations are disproportionately affected by dental problems and may be influenced by lack of access to dental care. Barriers to accessing dental care and use of emergency department (ED) services for dental needs were studied using interviews and ICD9 code analysis for a local hospital in rural Oregon. Barriers to accessing dental care include transportation and appointment availability for Oregon Health Plan (OHP) patients and cost and appointment availability for underinsured or uninsured low-income patients. Dental appointments and free preventive services are available for Native American patients suggesting other barriers to good oral health. Uninsured patients and Medicaid patients followed by Native American patients represented the largest percentage of patients seen in the ED for dental problems. Preventive resources and education about oral health in the community are limited. These results indicated that lack of access is only one barrier to poor oral health. Increasing preventive services, educational resources and community awareness about oral health may be more beneficial in improving oral health outcomes. Access to Care and the Impact on Emergency Department Utilization in Madras, Oregon Project Date: 3/19/2007 Access to health care is an important issue nationwide and is particularly salient in Oregon right now with multiple health care reform measures headed for the legislature. Utilization of emergency services can be used as a proxy to measure access to primary care. Key informant interviews were administered in tape-recorded sessions with health care providers and administrators in a rural Oregon community. The key informants were providers and administrators from Mt. View Hospital (MVH) in Madras, Oregon and from the four clinics that serve MVH. The interview sought to explore primary care providers' perceptions and experience with access to care issues in their communities, including questions about what affects access, trends in access and utilization, perceived needs to improve access and delivery of care, Emergency Department use, and strengths and challenges of primary care. Interviewees indicated that access to care is affected by health insurance, cultural and educational barriers, and common (misperceptions. Trends include a changing population that brings changing health care demands and narrowing financial margin. ED is thought to be overused for non-urgent/non-emergent care, in particular by those who feel no financial consequence. In the opinions of providers as well as administrators, access needs to be improved by legislation that changes the structure of health care programs. Mental Health Resources in Grant County, Oregon: Current Status, Recent Changes and Accessibility to Patients Project Date: 10/16/2006 In 1973, the state of Oregon established a regional system of county community mental health programs to provide basic mental health services to all residents and alternatives to hospitalization for certain residents needing higher levels of mental health care. Since then, the movement of deinstitutionalization and the Oregon Health Plan, have contributed greatly to the number of people who seek care at county mental health programs across the state. Grant County’s community mental health program, the Center for Human Development (CHD), located in John Day, Oregon, is the only resource providing solely mental health services for the county’s 7,800 residents. Interview with CHD administrators identified the following challenges: lack of and difficulty retaining trained mental health professionals at CHD, ever decreasing funding and reimbursement for services, social stigma regarding mental health care, and difficulty perceived by CHD with interfacing with the existing family practice clinics in John Day. Additionally, the Strawberry Wilderness Community Clinic (SWCC) family practitioners have difficulty making successful referrals to CHD, getting progress reports from CHD on referred patients, and staying current in diagnosis and treatment of less common psychiatric conditions. Therefore: 1) an informational patient handout about CHD was prepared for distribution to SWCC patients, 2) conversations between CHD and SWCC were initiated to establish designated SWCC space and time for a CHD counselor to see referral patients, and 3) conversation was initiated to establish a designated family practitioner who could be contacted for medication prescription in the event of psychiatric crisis. Increasing Access to Health Care in Hood River County: Mobile Health Unit Project Date: 10/16/2006 Millions of Americans do not have access to health care especially in rural communities. Hood River County has a population of 19,691 with the following characteristics 18.1% are uninsured, 14% live below the poverty level, 15.5% on disability between ages 16-64, 36.2% of children on free or reduced lunch, and 27.2% are Hispanic. The barriers preventing people within Hood River County from accessing health care include transportation, distance to care, uninsured, underinsured, immigration status, language barriers, and lack of knowledge on how to access health care. Providence Hood River Memorial Hospital (PHRMH) serves Hood River County and is located in Hood River. PHRMH identified lack of access to health care as a major problem within the county and created Mission in Motion – Mobile Health Unit (MHU) to bring access to health care to the people of Hood River County. After interviewing employees and observing the MHU in action I learned about the MHU and how it was started. MHU is a 35-foot RV purchased from eBay and refurbished into a mobile health clinic that services the small communities of Hood River County. It is staffed by physician or physician assistant, medical assistant, and driver. The mission of the MHU is to provide first time medical visits to patients that do not have access to health care or do not have a primary medical home and then set them up with a permanent medical home. In the first weeks of service 32 patients were seen with the top three reasons being blood pressure checks, high blood glucose, and cold/sinus infections. The MHU is still in its early phases and there are some concerns regarding potential for abuse as a primary care center. Patients have been appreciative of the services. The community of Providence Hood River health system should be applauded for their efforts to increase access to health care among the population of Hood River County. Patient Centered Education Materials in Klamath Falls Project Date: 10/16/2006 Klamath Falls, OR has a population of around 42,000 people. For many this would call into question it’s designation as a rural community in the state of Oregon. Due to its larger population, however, Klamath Falls provides medical services to many residents of surrounding communities that are completely devoid of medical care. With such a large portion of the patient population located so far from the clinic, I felt that the creation of some patient education materials would help patients learn more about their healthcare outside of the clinic. To accomplish this I created the brochure “Finding Breast Cancer Early with Breast Self Exam” and the handout “Is the new HPV vaccine right for you or your daughter?” The brochure on breast self exam was created in enough time to get some feedback from patients coming in for their annual well woman exam. Overall, they were appreciative of the brochure, but for the most part they ignored it. This didn’t allow for a lot for feedback, and instead it made me question whether my initial assumption about the necessity of such materials was true. I do feel that both of these handouts will be helpful to some of the future patients in my preceptor’s practice, but I also wonder what other ways there are to provide education outside of the clinic. This project definitely got me thinking about other options. Gay, Lesbian, Bisexual, and Transgender Health Resources in Madras, Oregon Project Date: 10/16/2006 Several studies have estimated between 3 and 10% of the U.S. population are gay, lesbian or bisexual. Small towns often have very few organizations or agencies to support this minority. This project looks for resources for gay, lesbian, bisexual and transgender (GLBT) individuals in the town of Madras, Oregon. Local health providers and administrators were interviewed to identify steps that have already been taken to support health needs of GLBT patients. In addition, using several national health resources, suggestions were gathered for improving the clinical atmosphere and health care for GLBT patients at one local clinic and hospital in Madras. The findings and suggestions collected during this process were presented to and discussed by a group of family practice physicians in the community. Utilization of the ER in Madras: Implications for health care availability and health care costs. Project Date: 9/11/2006 Between 1992 and 1999, the amount of ER utilization increased by 14% from 89.8 million to 102.8 million visits annually. This increase continues. US health care spending has also increased steadily, with rates of increase now in the double digits. Over-utilization of the ER has translated to increased health care spending, as well as inadequate long-term care for the patient. By analyzing the characteristics of patients admitted to Mountain View Hospital ER in Madras, we may gain some insights into the determining factors involved in patients' decisions to go to the ER instead of a primary care clinic. Madras is a rural community in central Oregon with unique health care issues related to its need for greater clinic accessibility, its shortage of primary care providers in the face of a growing population, and its housing of a larger subset of uninsured patients than Oregon as a whole. Mis-utilization of Mountain View Hospital's ER is a problem and solutions are discussed. Chronic Pain Management and Prominent Issues Among Rural Health Professionals in Baker City, OR. Project Date: 9/11/2006 Chronic pain management continues to be a major issue in the health care arena. Particularly in rural communities where access to multidisciplinary pain centers is acutely limited, the issue of proper care and treatment of pain remains a prominent concern for health professionals. The primary objective of this project was to understand the approach to pain management in a rural family practice clinic in Baker City, Oregon and identify available community resources that aid in the treatment of patients with chronic pain. Informal discussions with physicians, nurses, physical therapists, and pharmacists helped in elucidating current attitudes of chronic pain management and the challenges associated with its adequate treatment. Analysis of patient records allowed closer study of prevalent diagnosis and the medications used for pain treatment. The overall conclusion of this student is that there is an ever growing need to continually evaluate and discuss challenges in pain management and assess the adequacy of current protocol. The adoption and consistent use of pain contracts between patients and physicians is one desirable step towards the better monitoring, and therefore, better care of patients in pain. Access to Health Care Services on Warm Springs Reservation: A Needs Assessment for a Mobile Health Unit Project Date: 9/11/2006 A mobile clinic offers the ability to provide primary medical services to individuals and families living in remote rural areas. While a mobile clinic may not offer the most efficient means for health care delivery, many communities may find that its value—measured by health services provided to people with few other resources—is worth the effort. Mobile medical health programs offer the possibility of reaching populations who otherwise may not access traditional health care services. Poverty and lack of mobility are examples of life circumstances that can create insurmountable barriers to obtaining these services. This project was the first step in determining the need for a Mobile Health Clinic on Warm Springs Reservation. I compiled quantitative patient database information on community access to the Warm Springs Clinic. I developed and held a Focus Group, as well as employed a written survey tool, to gather qualitative input from community members. The next step of this project will be to obtain funding through a grant, which is a project I would like to continue to work on with a future student placed at this site. Successful Aging: Does Reedsport have what it takes to help its citizens over 65 age successfully. Project Date: 9/11/2006 In 2004, there were 36.3 million Americans over 65 years old; by 2030 this number will reach 71.5 million, a whopping 20% of the U.S. Population. In order for the aging population to age successfully - to have low incidence or risk or disease, to maintain mental and physical function and to actively engage in life - there must be certain community resources in place to help this happen. Reedsport is a community with many resources in the areas of community involvement, transportation and housing all of which influence how well people age. Reedsport offers those over 65 many opportunities to stay connected to the community, but the transportation and housing have room for improvement. Rural vs. University Medicine: A comparative review of data Project Date: 8/7/2006 Rural communities in Oregon face many obstacles to adequate health care relative to their urban counterparts, especially those with direct access to a teaching hospital. Among the more serious of these are: a lack of specialty care, a smaller selection of primary care, greater numbers of "working poor," and fewer clinical options for low income patients. Most medical students at OHSU are not exposed to non-university medicine until their third year of school, and even then, a miniscule percent of their overall education is dedicated to these pursuits. This project attempts to create a framework by which OHSU students can begin to understand the differences between rural and university health care settings before their clinical years. Access to Abortion Resources in John Day, Oregon Project Date: 8/7/2006 Current abortion trends indicate that the availability of providers is declining in rural areas. In 2000, 78% of all Oregon counties had no abortion provider. As a result, women must travel longer distances, overcome economic barriers and risk exceeding gestational limitations to terminate their pregnancy. John Day, Oregon is no exception to this trend. Six physicians, 1 NP and 1 PA were interviewed regarding how they provide resources to women seeking abortions. Although no providers exist, 87.5% of the health care workers said they would refer women for an abortion if she asked. In the case of rape or incest, 62.5% said they would “always” include termination in their discussion with the patient. In the past year, the 5 referrals that have been made were from the two female providers. Due to concerns over confidentiality and negative repercussion from the community all agreed that a local abortion provider would not be accepted or used effectively. For rural women, the drawbacks of leaving one’s community, including higher risk of exceeding gestational limitations and money, do not appear to outweigh benefit of anonymity. Management of Mental Health Emergencies in John Day, Oregon Project Date: 8/7/2006 Resources for appropriate treatment of mental health crises are limited in rural communities. The purpose of this project is to assess the infrastructure and clinical support for managing mental health crises in John Day, Oregon. This investigation included discussion with health professionals from the Blue Mountain Hospital and within the Grant County Department of Mental Health. These organizations provide care to the population of Grant County, as well as any patients presenting to the Blue Mountain Hospital Emergency Department. In addition to discussion with health care providers, literature searches were performed with the goal of assessing the strategies currently used by other rural communities for providing psychiatric care. In the course of this investigation, it was identified that the lack of a psychiatric hold unit within Grant County creates a particular challenge for managing patients in mental health crisis. Therefore, the discussion of this investigation will focus on this particular need and explore possible approaches to addressing the problem. The Bridge Assistance Program: Improving access to necessary health care in Florence, OR Project Date: 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. Incorporating Dental Health into the Role of the Primary Care Provider in Baker City, OR. Project Date: 5/1/2006 Dental disease is problematic in the United States, especially in the population of poor underserved children. Baker City, similar to many rural areas is composed of a large number of persons below the federal poverty line. The children in Baker City, therefore, are at a greater risk of developing dental caries and other dental complications. In an effort to incorporate the primary care provider into the dental screening and health of the pediatric population in Baker, a project was designed to help screen children seen in the clinic and assist in referring these patients to the appropriate dentist. The primary question that this project was intended to answer when is the best time for children to have their first dental examination, and how can primary care practitioners assist in this screening? To aid in this dilemma, a brochure was generated based on information gathered from a local dentist and an extensive literature search. In conclusion, pediatricians and family health care providers may be able to play an important role in improving the dental health of their patients who have difficulty obtaining access to professional dental care. Emergency Room Utilization in Harney County Project Date: 2/13/2006 Proper utilization of emergency departments in rural communities is important due to the shortage of local doctors and lack of a full-time emergency medicine (EM) physician. When the same physician is caring for patients in clinic while on-call in the emergency department (ED), it is important that patients be using the emergency room (ER) for urgent, acute issues. I chose to investigate the patterns of emergency medicine use in Harney County, population 7000, over a 2-month interval. I looked at principal diagnosis and whether the patient was admitted to the hospital, put on a 23-hour observation, transferred to another hospital, or discharged directly from the ED. I designed graphs looking at top 10 diagnoses, common system-based diagnoses and outcome in terms of discharge. I discovered that the majority of patients in Harney County are utilizing the emergency room for urgent or acute issues. Principal diagnoses appear to be typical of any emergency department. Lastly, I identified some of the common diagnoses that probably did not warrant an ER visit and what we can do in the future to help decrease the volume and costs in the ED. Bringing order to chaos: Improving the referral system at North Bend Medical Center Project Date: 2/13/2006 The process of referring a patient from a primary care office to a specialist has become increasingly complicated in both dealing with insurance companies as well as the office-to-office referral. This has the unfortunate consequence of creating a barrier to patient care as well as adding an enormous financial burden to medical offices in the form of administrative duties. The pediatric clinic at North Bend Medical Center identified a need to address this problem in order to increase efficiency and save money. The goal of this project was to clearly define the problem, understand its cause, and develop a potential solution. This was accomplished through a literature search to understand the problem from a broader perspective, and interviews with key people involved in the referral process throughout the state of Oregon. Ultimately two potential solutions to the problem at NBMC were identified: one, the need for appropriate staffing in order to handle the increased demands of the referral process, and two, the need for a referral guide that identified specialists that NBMC commonly refers patients to, contact information, as well as the necessary procedure one must go through in order to refer a patient. For this project, the referral resource was created and has been well received in the office. In the intervening time, an additional office staff member has been hired to handle referrals that will start in the near future. Spanish and English Asthma Action Plans in Klamath Falls, OR Project Date: 10/17/2005 Asthma is a serious health concern among the pediatric population in the United States. It affects approximately 9 million children under 18 and accounts for at least 2.9 million visits to pediatricians each year. Asthma is the most common chronic illness of childhood, and hospitalization rates for childhood asthma have increased despite improvements in asthma therapy. While asthma affects people of all races and ethnicities, the under-treatment of asthma among certain racial and ethnic minorities is well documented. There are two main causes that have been found thus far as reasons for this disparity. The first reason is lack of access to appropriate health care for minorities and underprivileged populations in general. The second reason is that the health care provided is inconsistent with the guidelines of the National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute (NHLBI). While the lack of provisions of adequate health care for all of the nation’s children is appalling, this paper will be focusing on the second issue, the general lack of adherence among pediatricians and family practitioners nationwide, including Klamath Falls, Oregon, to follow the guidelines of the NHLBI, by not distributing appropriate information on asthma to the Spanish-speaking population or to the general population as a whole. The purpose of my project was to assess how many primary care clinics in Klamath Falls, Oregon, provided asthma action plans in English or in Spanish to their patients and to provide asthma action plans to those clinics that didn’t have any. Healthcare for the Underserved Population of Grant County. Project Date: 9/12/2005 Rural areas in Oregon tend to have large percentages of patients on Medicare or Medicaid than do larger more metropolitan areas. Grant County Oregon is served by four family doctors who not only see patients during clinic hours, but are on call 24 hours a day, seven days a week to staff the emergency room at Blue Mountain Hospital, the only hospital in the county. Grant County has a very vulnerable and needy population in terms of the ability to access and pay for medical care. 25% of people live at or below the poverty level, and 60% live at or below 200% of the poverty level. More than 60% of the patients who are treated at the Blue Mountain Hospital are on either Medicare or Medicaid. According to the US Census Bureau, about 18% of the population is living with some sort of disability. This situation is a reality in Grant County. Medicare and Medicaid programs only paid about two thirds of the charges that were billed to them from the Strawberry Clinic. This resulted in a loss of $30,000 last year. In March, 2005, the clinic became a Rural Health Clinic in an attempt to continue caring for the rural community. ASSET: An Effort to Improve Outcomes for Acute MI Patients in Rural Southwestern Oregon and Northern California Project Date: 4/25/2005 With the increasing numbers of patients with coronary artery disease in this country spanning from metropolitan cities to rural communities, there is a growing population of patients at risk for acute myocardial infarction. Successful treatment of acute myocardial infarctions requires adequate and prompt identification and transfer to a facility for definitive treatment. The most effective treatment for ST elevated myocardial infarctions (STEMI) is percutaneous coronary intervention (PCI). Rapid PCI is the treatment of choice to minimize morbidity and mortality from STEMI. Unfortunately, time is heart muscle in the event of a heart attack. In rural communities, local hospital evaluation, transport to the nearest cath lab many miles away, and activation of the cardiac care team leads to a delay of 2 hours or more. The ASSET program developed by Dr. Brian Gross in Medford, Or has attempted to minimize the time delays and get cardiac patients in rural communities to definitive catheter treatment in a timely fashion. The program involves local rural community hospitals and their ambulance services as well as a group of on call interventional cardiologists in Medford to serve a nearly 50 mile radius around the Medford area. The protocol allows for first responders to identify STEMI patients in the field and bypass the nearest local hospital to transport the patient to a pre-alerted cardiac intervention team in Medford. The outcome was a decrease in the morbidity and mortality associated with time delays accrued in the rural setting and to make rural Oregon the “safest place to have a heart attack”. Multiple Strategies Designed to limit Medication costs for the underserved at the West Salem Clinic Project Date: 4/25/2005 Medication cots in the United States continue to trouble the patients taking the medications and the physicians prescribing them. This study attempted to identify and explain the many strategies the Northwest Human Services West Salem Clinic is using to combat therapeutic costs. The design was collection of information and data from multiple sources regarding several current methods currently being used at the clinic. All staff involved with patient care as well as staff specifically dedicated toward cost reduction programs were observed, studied, and queried regarding the ins/outs of these programs. This project will allow for a wonderful synopsis for clinics to possibly emulate the medication reduction cost programs currently being implemented at the NHSWSC. Identifying Obstacles to On-time Childhood Immunization in Baker County Project Date: 3/21/2005 Background: 77.6% of Baker County’s 24-month-old children were fully immunized with the CDC’s recommended 4:3:1:3:3 series of vaccines (4 DTaP, 3 Polio, 1 MMR, 3 Hib, 3 HepB) in 2004 (vs. 69.8% of all Oregon children vs. 90% Healthy People 2010 goal). Objective: Identify obstacles to full immunization coverage of children at 24 months of age in Baker County. Methods: Telephone survey of parents of the 130 children ages 12 to 24 months in the Baker County Health Department immunization records regarding obstacles to on-time immunization. Interviews with the county immunization nurse, Baker City family practitioners, and Oregon state immunization program staff. Literature review for vaccination rate improvement methods. Results: One nurse at the Baker County Health Department immunizes 96.3% of that county’s children. Parents cite difficulty getting an appointment within the month and the need for reminders for vaccination schedules and for individual appointments. Cost and transportation are not common obstacles. Children’s immunization records are not checked at their doctor appointments. Conclusions: Baker County’s child immunization coverage may be improved by decreasing the appointment wait time, instituting a recall/reminder system for all children, and checking immunization status at every encounter with the health care system. Use of Alternative/Herbal Medicines Among Family Practice Patients in Rural Eastern Oregon Project Date: 3/21/2005 The popularity of complementary and alternative medicine (CAM) among the general public is irrefutable.1 It is also increasing.2 Importantly, the greatest relative increase in CAM use between 1997 and 2002 was seen for herbal medicine.3 In parallel with this rise there is increasing evidence citing reactions and side effects of alternative/herbal medicine use as well as possible interactions with conventional medicine.4,5 A study in 2002 looked at CAM use among primary care patients in a rural setting in northern Pennsylvania.6 However, there is no previous study that has looked at its use, and specifically alternative/herbal medicine use, in rural eastern Oregon. This study has two (2) aims: 1) to determine the frequency and types of alternative/herbal medicines being used by patients in Grant County, Oregon; and 2) to determine the rate of physician notification of alternative/herbal medicine use and reasons for not disclosing its use. Methods: A questionnaire was distributed to 235 adult patients in two family practice clinics in John Day, Oregon. Results: Response rate was 99.6% (235/236). Fifty-five percent (55%) of patients reported using at least one form of alternative/herbal medicines in the past 12 months. The most common alternative/herbal medicines used were green tea (16%), megavitamin (13.9%), glucosamine (11.5%), Echinacea (11.5%), fish oil (6.9%), soy products (6.6%), and ginseng (3.9%). The number one reason to use alternative/herbal medicine was for health maintenance (22.6%). The majority (52%) of patients self-prescribe alternative/herbal medicines. Only 46.5% of patients told their physician about their use of alternative/herbal medicine. Conclusion: A significant number of rural family practice patients are using alternative/herbal medicines. A public educational campaign, with inclusion of the need to report such usage to the family physician, should be implemented, and questions on the use of alternative/herbal medicines should (continue to) be incorporated as an integral part of the history taking by primary care physicians. Barriers to Enrollment in the Oregon Medical Marijuana Program in Madras, Oregon Project Date: 2/7/2005 Since its approval by voters in 1998, the Oregon Medical Marijuana Program has provided legal protection for enrolled patients to grow and use marijuana for symptomatic treatment of cancer, glaucoma, HIV/AIDS, agitation due to Alzheimer’s Disease, and any medical condition that produced cachexia, severe pain, severe nausea, seizures, or persistent muscle spasms. Initial estimates predicted growth of 500 members per year, but by July 1, 2004, OMMP membership cards had been issued to 10,196 people. Despite the popularity and rapid growth of the OMMP, many barriers exist in enrolling patients with qualifying medical problems. Through interviews with physicians, a physician’s assistant, home health & hospice nurses, patients, as well as chart reviews, barriers to enrollment in the OMMP were identified, some of which are unique to the rural community in Madras and others that apply to patients statewide. Information regarding the OMMP, Madras Medical Group’s enrollment in the program, and barriers to enrollment were presented in a lecture to the clinic’s providers with the goal of increasing provider understanding of medical marijuana in Oregon. Increasing Access to Prescription Medications in the Elderly Population of Malheur County Project Date: 2/7/2005 Many elderly patients take prescription medications on a daily basis; however, the rising costs of these medications make it difficult for patients, especially those with fixed or low incomes, to afford them. For elderly patients in the rural setting, the problem of access to affordable medications is even greater because of the lack of social workers and other staff available to assist patients with applying for prescription assistance programs, Medicare discount cards, and other lower-cost prescription medication programs. Many patients report that their prescription drugs cause them financial hardship. This often leads to patients skipping or cutting down on doses or not filling the prescriptions at all. This is frustrating for both the patient and physician who both are trying to manage what are usually complicated medical conditions. Oftentimes, the physician, nurses, and other office staff take on the responsibility of helping patients access medication assistance programs, which is both time and resource consuming for the staff. This project looked at the elderly population represented in one family practice office in Ontario, Oregon, which is the largest city in Malheur County. A prescription drug questionnaire was utilized to query patients about out-of-pocket prescription medication costs, methods of cost savings (e.g. buying online, skipping doses, etc), and knowledge about cost saving prescription drug programs. A total of 22 patients, age 65 and over, completed the survey, with 45% responding that the cost of prescription medications cause them financial hardship. These patients spent an average of $187.00 a month on prescription medications, and 70% report having no prescription drug coverage. Of the 55% that did not experience financial hardship, 92% had some type of drug coverage and spent an average of $49 a month on medication. Of all the patients surveyed, 45% report using cost-saving methods, including using mail-order companies in Canada, price comparing among different pharmacies, using samples, skipping doses, and not filling prescriptions. Ultimately, the goal of this project was to identify ways to help patients gain access to affordable prescription medications in the most time and resource efficient manner. Development of a simple one page handout with prescription medication resources and consumer buying tips, which could be easily distributed to patients, was found to be the most efficient and helpful to patients. Assessment and Treatment of Acute Psychiatric Disturbances in Madras, Oregon Project Date: 1/3/2005 A review of medical records in the Madras Mountain View Hospital over the past year reveals that physicians in Madras, Oregon are not managing psychiatric emergencies up to the standards that they are capable of meeting. For instance, physicians in the Madras Medical Group are placing acutely psychotic patients in restraints or seclusion 61% of the time. This is significantly more than the 20% of time that experts find these measures appropriate. This difference is not likely a reflection of a threefold increased number of psychiatric patients in Madras compared to the rest of the country. Rather, it more likely reflects the fact that the psychiatrically ill population of Madras is not being appropriately cared for in emergent settings. In fact, experts would consider 60% of “holds” in Madras inappropriate. Fifty percent of patients placed in the Madras holding room did not even have a physician-documented psychiatric evaluation in their chart. The primary reasons for these problems are the limitations of a rural setting, increased level of complexity involved in emergent behavioral care, and rural physician discomfort with their acting role as psychiatrist. Madras does not have even a single community psychiatrist. These factors indicate that the Madras Medical Group would benefit from a review of appropriate delivery of acute psychiatric care. Specifically, an approach that better balances the rights of patients with considerations of safety and good standard of care is presented here and contrasted with the current level of care in Madras. Recommendations for improved assessment, charting, and intervention are offered. Furthermore, an outline of appropriate pharmacological treatments is provided. The Use of Flexible Sigmoidoscopy in a Rural Family Medicine Clinic Project Date: 1/3/2005 Colorectal cancer is a largely preventable and yet prevalent cause of mortality in the US. Accordingly, professional organizations with published guidelines for screening recommend that all adults ages 50 or older receive screening for colorectal canter (1). Of the screening options available, colonoscopy is the most sensitive and specific test for detecting colorectal cancer (2). However, in many rural areas there is a shortage or even absence of colonoscopists. In one such town, Philomath, physicians at a family medicine clinic are working to fill this gap in cancer screening. Eligible patients of this clinic are actively encouraged to get screened via yearly fecal occult blood tests and flexible sigmoidoscopies once every five years. The sigmoidoscopies are performed in the clinic by the family physicians. This study assesses patient records of one of the Philomath physician's positive scope findings over the past five years. In evaluating follow-up colonoscopy and polyp biopsy results on these patients, it will be shown that flexible sigmoidoscopy is a useful tool in colon cancer screening. Not only can flexible sigmoidoscopy identify patients with polyps who are at higher risk for developing colrectal cancer, thereby helping to reduce the burden on limited colonoscopy resources, but it may also provide reassurance to those with negative findings. Perceived Availability of Physicians To Patients in the Clinical Setting Project Date: 10/18/2004 Access to medical care is often the main barrier to health in a rural community. While access can take on many different meanings for a community, I chose to focus on the perceived availability of physicians to patients in the clinical setting. I observed an independent Internal Medicine practice of 4 physicians and 2 nurse practitioners serving roughly 12,000 patients in a rural area. Over a five-week period, I observed office staff and physician perceptions that patients have many unrealistic expectations for the logistic aspects of their health care. I listened to patients’ questions and expectations regarding their care by the facility. Unnecessary phone calls and incomplete follow-up were two main complaints by office staff, while not being able to talk to a person on the phone and high cost of medications were consistent problems noted by patients. This informal research resulted in the formation of an educational handout to patients to improve their expectations of the logistics of their medical care. By improving patient knowledge of appropriate interactions with the office staff, it is hoped that there will be a decrease in unnecessary phone call volume, to ultimately improve access to the clinic for urgent concerns. Addressing A Possible Solution for Specialty Outreach Clinics. Project Date: 9/13/2004 OHSU Scappoose Family Practice was recently designated a Rural Health Center. While this designation provides adequate primary care reimbursement for Medicaid and Medicare patients, these patients still experience delays establishing tertiary care. To address a possible solution to this problem we researched the plausibility of specialty outreach clinics. We reviewed 1,000 referrals from the OHSU Scappoose Rural Health Center in 1999 to identify potential specialties with enough patient demand to warrant regular scheduled visits to Scappoose Family Practice Clinic. We also identified which specialties are limited to location by technology, and finally we asked the question if specialties did come to the Scappoose clinic on a regular schedule, would this expedite Medicaid and Medicare patient access to tertiary care. Our findings identified five tertiary specialties that have met these preliminary criteria; Orthopedics, Cardiology, Otolaryngology, Rheumatology, and Dermatology. Hepatitis C Virus Treatment Program Project Date: 9/13/2004 There are currently no available locate treatment programs to offer patients infected with the hepatitis C virus (HCV) living on the northern Oregon coast. The majority of patients infected with HCV, from Pacific City up to Astoria, have to drive into the Willamette Valley in order to receive treatment program at the Rinehart Clinic in Wheeler, Oregon. Materials were developed based on need for patient education materials, flow sheets to monitor treatment progress, and a protocol for providers to refer to when beginning the treatment of a patient. Information used to develop these materials came from the 2002 NIH Consensus on the management of hepatitis C, researched articles, and an established hepatitis C treatment program in the Willamette Valley. Patients needing treatment were identified by clinic records. The materials developed were reviewed by the physician and found to meet the clinic's needs for establishing a hepatitis C treatment program. Health Care Services Available to Undocumented Immigrants in Madras, OR Project Date: 9/13/2004 Policy changes within the past ten years have limited undocumented immigrants access to insurance and health care. Undocumented Hispanic immigrants, many of whom are farm workers, suffer serious health problems because of the conditions in which they live and work. Due to fear of deportation most do not seeking medical care or preventive services for themselves or their U.S. born children. Studies have shown migrant farm workers to be among the most vulnerable populations with poor health outcomes and limited access to care. Madras has a large Hispanic farm worker population many of which are undocumented. These individuals face barriers in accessing health care due to lack of insurance, poverty, and language and cultural barriers. This study attempted to ascertain what health care resources are available to undocumented immigrants in Madras. The project design consisted of gathering information through interviews at area health facilities and observing patient care visits at a prenatal clinic targeting this particular population. The rising cost of prescription medications continues to impact the lives of many individuals. Project Date: 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. Assessing the Resources Available to At-Risk Pediatric Patients Project Date: 8/9/2004 Individuals under the age of eighteen comprise approximately one fourth of the population of Baker County, Oregon. Nearly one fifth of these individuals live below the poverty line, which produces significant ramifications on this society as a whole. Physicians serving this population may offer not only medical services, but also refer other resources to these patients. Through interviews with representatives of community organizations and literature review, services available to pediatric patients who are of low-income families in Baker County were researched. In order to facilitate the awareness and utilization of these resources, patient education material highlighting medical, educational, social, spiritual, and recreational resources available to low-income Baker County pediatric patients was developed and distributed to various agencies in Baker City. The Road To Recovery: transportation for radiation oncology patients in Lincoln County Project Date: 8/9/2004 Traveling daily to radiation oncology centers for therapy is a roadblock in the treatment of some cancer patients from Lincoln County. A group of providers is in the process of making reliable and inexpensive transportation available to these patients. In this attempt, current information on radiation patients and where and how they receive treatment was needed in order to secure funding and garner support for this program. For this project, the necessary state and county cancer data was obtained from the Oregon State Cancer Registry and statistics and information were obtained from the Samaritan Regional Cancer Center (SRCC) regarding Lincoln County radiation patients as well as physician referral data. This information reveals the number of patients and the likely demand for transportation. It also shows that some patients referred for therapy are not receiving the treatment they need at SRCC. It is hoped that providing this information will aid in the process of securing reliable transportation for future radiation oncology patients from Lincoln County. Assessment of services available to seniors in Baker City, Oregon Project Date: 7/5/2004 The population of those over 65 in the United States is rapidly expanding, a trend that has profound implications for health care practitioners and organizations serving seniors. Rural communities in particular are seeing a surge in this population. Observation of physicians in Baker City, Oregon and their interactions with elderly patients demonstrated that primary care practitioners are often called upon to connect seniors with appropriate resources, both medical and social. Navigating the numerous agencies and trying to determine which services are provided can be frustrating for physicians, seniors and their families. A survey of services available to seniors was conducted, as well as interviews with organizations providing resources. It was concluded that while there are a multitude of opportunities for seniors in Baker City, a large portion of seniors were not making use of se services. Although there are a number of reasons for this, it is hypothesized that utilization of services may increase if health care providers are able to more easily access contact information. In order to aid practitioners in this endeavor, a comprehensive list of services for seniors in the Baker City area was produced. Hepatitis C infection Baker County - educating local healthcare professionals and at-risk populations Project Date: 5/10/2004 At larger than expected segment of Baker Countys population is at-risk for hepatitis C infection. Concurrently, Baker lacks sufficient resources for referrals for therapy with many of these people lacking insurance, making a consult from a gastroenterologist out of the question. Baker City's referral hospital is 130 miles across state miles in Boise, also home to the closest gastroenterologists. Although one local family practitioner has started administering antiviral treament, access for treament is still quite limited but has room for expansion. However, few local health care workers, including the county health department, have undergone training regarding the newest therapies and outpatient management techniques of the disease. Therefore, the goal of this project was to provide training and information for local health care workers involved in the care of hepatits C-infected patients, as well as educating Baker's intravenous drug use population regarding the risks and options for hepatitis C infection. To affect this end, a patient information pamphlet was crated, in addition to in-person presentations to both healthcare providers, as well as at-risk populations. The pamphlet explains basic infection about hepatits C, including outlining methods of transmission, stressing the importance of abstinence from alcohol, discouraging needlesharing, and receiving vaccinations against hepatitis A and B. These preventive interventions may aid in reducing the number of new infections, as well as educating those already infected who may be eligible to advocate for treatment. It may also remind providers to screen and consider treatment for hepatitis C and ensure improved hepatitis A and B vaccination rates. Facing the loss of obstetrical care in Grant County: Is the community prepared? Project Date: 5/10/2004 Multiple studies have shown that many rural Oregon clinicians performing obstetrical deliveries have already stopped or plan to stop providing this service in the near future. Despite malpractice subsidization efforts such as the Rural Medical Liability Financial Reinsurance, these rates continue to soar, forcing many physicians out of obstetrical practice. The number of physicians who routinely perform obstetrical care in Grant County has dwindled in recent years, such that only one family physician performing OB remains in this isolated county of 8,000 people and 5,000 square miles. If no viable alterative is identified, he, too, will likely stop providing OB care in one month and women will be left to drive long distances for prenatal care and their delivery. In the advent of this potential crisis, this project was designed to assess the community’s preparedness for this transition, as well as childbearing women’s intentions for obtaining prenatal care. These goals were obtained through two methods: 1) a 12-question survey of 33 pregnant and postpartum women that sought information on demographics, risk factors, barriers to receiving care elsewhere, and anticipated plans at the onset of labor, and 2) interviews with community health partners to identify problems, concerns, and potential solutions that might prevent or minimize the impact of the crisis. Survey results revealed a population of many Medicaid patients and first-time mothers. Although most women reported a willingness to travel for prenatal care, 82% stated they would go to the local hospital in Grant County at the onset of early labor signs, suggesting the need for continued emergency OB services. Results of the interviews with health leaders are summarized in a problem/solution format. The results were shared with the same community health partners to assist in their preparedness planning. Assessing Needs, Access, and Barriers to Alcoholism Treatment in the Rural Community of Grant County, Oregon Project Date: 5/10/2004 Alcoholism and its negative social, economic, and medical consequences increasingly pose major problems in the American society and important challenges in doctor offices, especially in rural settings where there are few available resources. It is the objective of this study to attempt to assess the needs for, the access to, and the barriers against alcoholism treatment in Grant County, Oregon. The design of the study includes multiple facets of researching work on available literature and published reports, reviewing medical records in medical facilities, meeting with personnel involved in alcoholism treatment programs, and attending Alcoholics Anonymous meeting, all of which focus on the population of Grant County, Oregon. Published data regarding the rate of alcohol misuse and abuse in Grant County which would be reveal a lower rate of alcoholism in Grant County as compared to that of the entire state of Oregon (6.7% vs. 7.8%). However, the needs for alcoholism treatment in Grant County are still considered greater that those of the rest of Oregon with finding of greater magnitude of negative consequences of alcoholism in Grant County, i.e., alcohol-induced death, alcohol-related traffic fatalities, adult alcohol-related arrests, and drunken driving arrests. It was so found that 207 people in Grant County sought treatments in four of major resources for alcoholism help in Grant County (Blue Mountain Hospital, Strawberry Wilderness Family Clinic, Grant County Center for Human Development, and Alcoholics Anonymous program) in the period of about one year through medical records. The rate of utilization of medical help of 207 makes up only 43.5% of the 476 in needs for alcoholism treatment, suggesting multiple barriers that are difficult to identify. Among these barriers are finance with Grant County being one of the poorest county in Oregon with high unemployment rate (16.9%) and low educational level (15.5% without high school diplomas), low affordability of alcoholism treatments (high rate of uninsured population of 16.47%), social stigma, and other factors unique to each alcoholism treatment options in Grant County. Transportation for Veterans to Portland VA Medical Center Project Date: 3/29/2004 Tillamook County is home of more than four thousand US Veterans. However, this is the only county in the state that does not have a van to provide transportation for its veterans to the Portland VA Medical Center. In order to have a van, the county must raise $25,000. Although the county does not have the funds to appropriate to the purchase of a van, the money can be obtatined through private sources. Delivery of and Attitudes About Hospice Care in Florence, Oregon Project Date: 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. Barriers to Obstetric Care in Reedsport, Oregon Project Date: 1/5/2004 With the loss of C-section coverage in 2002, the physicians at Dunes Family Health Care could not continue to provide deliveries at Lower Umpqua Hospital (LUH) in Reedsport due to the terms of the hospital's liability insurance. The object of this project was to examine the barriers to providing obstetric care in Reedsport, because many rural communities are dealing with this issue, and determine what might make rural obstetrics more stable. Who becomes a rural physician? Characterizing the Physicians of Oregon’s South Coast Project Date: 9/29/2003 There have been efforts to characterize rural physicians in hopes of correcting the shortage of health care in rural areas, and several generally accepted assumptions have emerged. This project aims to determine if these “basic truths” apply to rural Oregon, particularly the South Coast area surrounding the community of Coos Bay. A survey addressing these questions was sent to 99 physicians with a 46% response rate. To further investigate the belief that rural experiences increase interest in rural practice, an analysis of OHSU graduates before and after the implementation of the rural clerkship was undertaken. The data presented indicates that many of the accepted truths do not in fact hold up for the populations investigated. How does a county hospital in a town of 4,000 people afford a full-time MRI? A case of rural hospital success. Project Date: 11/10/2003 MRI is an powerful and important diagnostic tool but is a luxury that many rural hospitals cannot afford. This project focused on one such rural hospital, Tillamook County General Hospital (TCGH), that is currently completing installation of a full time MRI scanner. This rural hospital serves a population of just over 24000 people, yet it has managed to foresee economic viability for this expensive imaging modality. Interviews were conducted to MRI technicians at each of the 11 Oregon hospitals serving the Oregon Coast to establish the type of MRI services available, the number of patients scanned per week and per month. MRI cost analysis and comparison among the Oregon Coast hospitals was done via Health Care Financing Administration and American Hospital Association data made available on the world wide web. TCGH shows a slightly higher rate of MRI utilization than the average of the 11 Oregon Coast Hospitals, but Tillamook does have a higher proportion of it's residents as over the age of 65, based on Census 2000 data. Tillamook has the third lowest average cost per MRI ($451) of the seven Oregon Coast Hospitals with available MRI cost data. Only Gold Beach ($350) and Coos Bay ($128) have lower average costs per MRI, while the other reporting hospitals show charges of up to $600 and even $800 dollars. Budget data obtained by interviews with the TCGH administrators demonstrate confidence in the projected financial viability of the MRI scanner; further confirming that the timing is right for TCGH to implement a full time MRI scanner of its own. This will certainly increase access to this valuable diagnostic imaging modality while concurrently providing a revenue boost to ensure overall hospital viability at TCGH. OHP at Work in Rural Oregon Project Date: 9/29/2003 Although Medicaid provides health insurance for millions of Americans, there are problems associated with it that can hinder easy access to quality healthcare. Doctors frequently cite the low levels of reimbursement for services provided to Medicaid patients. Their offices must limit the number of patients on Medicaid in their practice so the higher reimbursement received from private insurers can make up for the losses incurred by treating Medicaid patients. Patients dependent on the government for their healthcare comment that they are not treated with the same respect as other patients, and can have a difficult time finding a physician willing to care for them at all. In 1993, a small group of physicians in Klamath Falls recognized these problems and decided they would takes some steps toward change. That year, Cascade Comprehensive Care (CCC) was birthed in Klamath County as a managed care program that would serve the county’s Medicaid population. Since that time, profitability for physicians and access to care have improved, and for the most part, the patients seem pleased. This project investigates the successes of CCC to present it is an alternative for managing patients on Medicaid. Statewide research is cited to show the relative success of this program, and the results of a survey completed by patients at the Klamath Pediatric Clinic are presented to show the success of this clinic which serves a population with a large contingent of Medicaid patients. One community's response to a chronic shortage of psychiatrists: Telepsychiatry Project Date: 11/10/2003 In Ontario, Oregon, one major issue in the access to psychiatric care and in the continuity of that care is a paucity of mental health providers. This project considers one alternative currently in use in the community-telepsychiatry. Telepsychiatry is effective and convenient in appropriate populations. Interviews of employees of two of three mental health agencies serving the Ontario region were conducted, exploring use of telepsychiatry. The correctional institution in Ontario provides mental health services to inmates by teleconferencing equipment based in Ontario and Portland, Oregon. This is a successful mode of treatment, delivering increased access to care, increased public safety and patient satisfaction. The community psychiatry agency in Ontario, Lifeways, utilized telepsychiatry until costs overcame that effort. They were informed about the Federal Commmunications Commission's support for rural telemedicine efforts. Evaluate Immunization Delivery and Suggestion of Strategies Project Date: 8/18/2003 Immunizations are one of the most successful preventive interventions. Unfortunately, not all children receive this intervention equally or on a timely basis. The objective of this study was to evaluate immunization delivery, address barriers to immunization, and suggest strategies by which rates can be improved at Dunes Family Health Center (DFHC) in Reedsport, OR. In conjunction with the Oregon Immunization Program, a retrospective analysis of all children ages 12-35 months, who received at least one vaccination at DFHC with dates of birth ranging from July 16, 2000 and July 15, 2002, was conducted. Analysis of 103 immunization records yielded coverage rates for children 2 years of age, as well as percentages of late starts and missed opportunities. The up-to-date coverage rate at DFHC for children at age 2 years that are fully covered with 4 DTaP: 3 Polio: 1 MMR: 3 Hib: 3HepB is 46%; 6% of children were found to be up-to-date by the date of assessment. The percentage of late starts is 14%, and that of missed opportunities is 28%. Decreasing both the percentage of late starts and missed opportunities by addressing barriers and deficiencies in immunization delivery would improve coverage rates. A Glance at Immunizations in Baker City, OR Project Date: 7/7/2003 Childhood immunizations continue to pose a challenge within the public health sector. Baker City, OR, possesses a rare immunization program in that the County Health Department immunizes 94.5% of the children in Baker County. The immunization rate of children ages 12-35 months in Baker County is 64%. This project examined immunization rates of the county as a whole in comparison to immunization rates of pediatric patients under the care of one Baker City physician. A list of patients between the ages of 12 months and 5 years was obtained from the Baker Clinic database. Permission was obtained from the patients' parents or guardians, and the patients' immunization records were then reviewed through the County Health Department. A total of 46 patient immunization records were reviewed. The immunization rates for children aged 12-35 months and 36 months to 5 years were 72.7% and 91.6% respectively. While these rates were higher than those of the county rates, the immunization goal still aims for close to 100%. Further investigation may be warrented to evaluate any missed opportunities or barriers that may impede immunizations. A clinic-based immunization program may also be necessary, but challenges remain in order to reach this stage. Mental Health Services in Grant County: Challenges & Progress Project Date: 8/18/2003 With budget cuts limiting the availability of services for mental health, small rural communities like Grant County are the hardest hit. The central goal of this project is to provide an initial framework of the nature of mental health services that exist in Grant County. The design for this project includes internet searches via the DHS website and an interview with the director of mental health services at the Center for Human Development. Grant County Center for Human Development is located in John Day, OR. It is the only place in the county that specifically provides mental health services. Yet, Grant County has a population of approximately 8000 people. As a result there is limited access to mental health services. However, other significant challenges include a limited staff, of which an overwhelming percentage is not appropriately trained to properly handle assessment and treatment planning. Furthermore, the study reveals that there is poor patient management and a laid-back approach to intervention. The encouraging aspect of the study is that the staff is receiving more training, a crisis worker has just recently been hired, and an improved method of documentation is being devised to better manage patients and the course of their treatment outcomes. Future plans call for the establishment of a psychiatric emergency unit in Grant County and contributions from residents and medical students in terms of sharing their time and knowledge with the mental health department staff in an effort to improve the quality of mental health services in Grant County. Getting It Out There:Developing a Health Care Resource Guide in a rural Community Project Date: 5/5/2003 The Community Health Improvement Partnership (CHIP) has been undertaking a large-scale health needs assessment in Reedsport, OR over the last two years. This has been done by written survey and town hall meetings. These efforts have yielded a set of health issues that the community finds important. The CHIP committee is now at a stage to start implementing solutions to these findings. As my project, I participated in the CHIP committee on health information and referral. The community had indicated that it was difficult to find the appropriate health resources. To that end, the committee has begun compiling a list of healthcare resources and organizing them in a searchable database to be linked to the Lower Umpqua Hospital website and printed for use in establishments that provide resources for a large number of people. The resource directory is expected to be a comprehensive document outlining services, points of contact, hours, etc. It is expected that it will take about 6 months to complete, therefore; an interim guide will be used that simply provides resource names and phone numbers. Implementation of a group-based health care delivery model in Florence, OR: exploring a possible solution to this community’s increasing health care deficit Project Date: 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. The Waterfall Clinic Development of Future Funding Project Date: 12/30/2002 The Oregon Health Plan serves as a safety net for individuals who earn income at or near the federal poverty limit. There is a weakness in this coverage plan. There are many who are classified as the “working poor”. They can be defined as those who live at 101%-185% of the federal poverty line. These are the individuals who work in service industries, or small businesses that do not provide adequate health coverage. They work hard, but lack resources to pay for medical care. My project was designed to assess this need in Coos County and help provide a solution for it. I worked closely with a local clinic known as the Waterfall Clinic. This clinic is a non-profit clinic designed to care for individuals without medical insurance. The clinic provides services on a sliding fee schedule, based on family size and income. Due to current difficulties with federal grant resources, the clinic is losing a large portion of its funding. My project involved identifying resources of funding, creating a marketing plan to attract funding, and writing a grant proposal to a local foundation for $20,000. There are a multitude of research studies that have shown how preventative care in a primary setting can prevent large expenditures in the emergency setting. By providing these services, Waterfall Clinic can help prevent serious morbidity and reduce the costs of health care for the community as a whole. Help for the Homeless? An exploration of the Assistance Programs Available to the Homeless Population of Salem, Oregon. Project Date: 5/6/2002 Conducted in the community of Salem, Oregon from May to June of 2002, this project sought to explore the needs of the city's homeless population in order to determine if adequate assistance programs are currently in place. Initial interviews with homeless individuals seeking medical treatment were followed by an attempt at characterizing the demographics of this position. Utilizing this initial data, a survey was prepared, and distributed to homeless individuals, that sought to identify which needs were not being satisfactorily met by Salem-area assistance program currently in place. Each agency was contacted and a description of the provided services was obtained, with emphasis on theconcerns raised by survey responders. It was then possible to compare the perceived needs of the homeless population with the services in place to address them. In general, the homeless of Salem, Oregon are pleased with the assistance they receive, but are not very aware of all the programs and agencies available. Further, there is limited communication between these various agencies, and each assistance program is not fully aware of the others in the community. To address this weakness, a current Salem-area resource guide, detailing the services offered to the homeless, was prepared and distributed to local agecies so that a more coordinated effort can be achieved. A Newly Opened Urgent Care Walk-in Clinic in Lebanon, Oregon: Improving Access or Providing a Safety Net. Project Date: 8/13/2001 Access to routine health care can be difficult in some rural communities for several reasons, these include a shortage of primary care physicians, lack of a facility, lack of insurance, etc. As a result, patients have to use Emergency Departments for care that is not emergent. To provide a more affordable alternative, Lebanon Community Hospital opened an Urgent Care within the hospital. This study is a cross-sectional study to assess the patient population that is using a rural Urgent Care. The results of this study indicate that this particular Urgent Care is being used for its intended purpose of improving access for patients who are unable to be seen by a PCP. Although there is a segment of the population who do not have a PCP or insurance, the Urgent Care is providing an alternative to the more expensive emergency department visit. Access To A Creative Solution: The Siuslaw Plan: Are Clinic And Emergency Department Personnel Doing Their Part? Project Date: 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. Back to subject search page or search by preceptor site