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. Transfer of patients by ground ambulance vs. fixed wing aircraft from Coquille to Eugene: Evaluation of the Decision Process and Resolution of Policy among Team Members Project Date: 10/12/2009 Patients who present in, or who progress to, a state of critical condition outside the ability of the rural facility need to be transported to a larger facility with greater access to technology and personnel. For patients in Coos County, the most frequent transfer destination is Eugene. The options for transport are ground ambulance, rotor wing aircraft, or fixed wing aircraft. Each has their advantages and disadvantages, and each has a place in patient transfer depending on the circumstance. There is a disagreement among healthcare personnel over when to transport patients by air, and when to use ground ambulance. In short, the first question to be answered is this: Is fixed wing aircraft ever a reasonable option between these two locations? The second question is how can we bring about reconciling the two dissenting factions? Factors Associated with No-Shows and Methods for Intervention in a Stayton Family Medicine Clinic Project Date: 9/7/2009 Patients who schedule clinic appointments and fail to keep them contribute to decreased opportunities for patient health prevention and disease monitoring and management, and also contribute to wasted clinic resources and decreased productivity. This project was conducted to identify and describe factors associated with why patients do not keep scheduled appointments, and discuss potential strategies to increase attendance at appointments. Methods: 110 electronic medical record (EMR) patient charts at a Stayton Family Medicine clinic were randomly selected from 442 no-shows identified from 2004-2009. Results: 442(<5%) no-shows were identified from 2004-2009, or about 1 no-show per provider per week. 110 patient charts were reviewed, 45(40.9%) male and 65(59.1%) female. Mean age was 37.4 years old (YO), with 17(15.5%) less than 12 YO, 8(7.3%) 12-17 YO, 40(36.4%) 18-40 YO, 31(28.2%) 40-64 YO; 14(12.7%) over 64 YO. Tobacco use was reported in 61(55.5%) patients, with 6(9.8%) previous tobacco users, 49(80.3%) current tobacco users, and 6(9.8%) recipients of secondhand smoke. The 6 cases of secondhand smoke were children 2-15 YO. Alcohol use was reported in 40(36.4%) patients. Mean number of medications reported was 3.7 and 4.5 for non-tobacco and tobacco users, respectively. Mean number of past medical history diagnoses reported was 4.3 and 6.0 for non-tobacco and tobacco users, respectively. Conclusion: The rate of no-shows at the Stayton clinic is much lower than the average rate found in many studies. Over half the no-show patients reviewed in the study were reported to be smokers. Most patients are relatively young with 59% who were less than 40 YO. Several factors must be considered in deciding which methods to implement to reduce no-show rates among patients. Warm Springs Fire and Safety - EMS Funding and Training Challenges Project Date: 9/7/2009 Rural EMS agencies are under similar strains as every other aspect of health care. They struggle to recruit, train, and retain providers. The funding for these agencies, especially in a struggling economy, is at a bare minimum. Many of these agencies in the past have been able to provide continuing education and equipment upgrades with the help of grant funds. The Warm Springs Fire and Safety service is no exception. I tried to identify additional funding or resources that were not being utilized. After a local and regional search I was not able to find any financial sources that had not been evaluated, but I was able to offer some strategies to try to maximize the resources that are available. I also provided 5 hours of training to 2/3 of the staff at this department. Exploring Insider Perspectives on the Future of Rural Medicine Project Date: 9/7/2009 The growing deficit of rural healthcare providers has been studied and approached from several different angles. This project seeks to understand the barriers to fostering more healthcare providers from within rural communities by investigating available resources and obtaining perspectives of different members from the community of Reedsport, OR. This was done by surveying and interviewing healthcare providers at the Dunes Family Health Care clinic (DFHC), faculty and staff at Reedsport High School (RHS), and the senior class at RHS. A particular look was taken into potential barriers of inadequate educational and financial resources, lack of student awareness of the range of healthcare careers, and lack of interest in health and science. A presentation was also given to the senior class of RHS to address these areas and a follow-up survey was given to assess changes in awareness and interest. Addressing rural physician shortages through retention: an assessment of physician retention in Ontario, Oregon Project Date: 9/7/2009 Rural areas continue to suffer from a shortage of primary care physicians. Recruitment of new physicians to these areas as a means to address the shortages has long been studied, but the impact of physician retention is now being examined as an important factor in care access. The role of physician retention in rural town of Ontario has yet to be studied. A descriptive analysis of practice length, specialty and reason for resignation or date of anticipated resignation, if applicable, was completed for 102 physicians on-staff for Holy Rosary Medical Center (HRMC) for at least one month between January 1996 and October 2009. The results demonstrate a significant difference in the average practice years of retained and resigned physicians. They also indicate that the four most commonly cited reasons for resignation are: poor fit, desire for bigger city, completed obligations, and family concerns. Results also revealed high turnover among family physicians following completion of service obligations for visas or loan repayment programs. Finally, the analysis predicted a significant shortage of primary care physicians looming in the near future of this community. Though limited in scope, this study identifies an immediate need for increased recruitment of primary care physicians to Ontario, as well as several starting points for addressing shortages through improved physician retention. Thinking about Health Care in the USA: A Health Care Primer Project Date: 8/3/2009 Health care reform has been one of the big political and social topics of 2009. With a president committed to reform and an equally committed opposition the tenor of the debate has been flooded with misinformation and intentional misunderstanding. The physicians at Dunes Family Health Care felt that their voices needed to be heard on the subject and that it was in part their responsibility to educate their patients. To do this they wanted to develop a tool that they could use to talk to their patients about the basic traits of the US health care system and the key elements of proposed reforms. Patient literacy levels and sophistication are limiting factors in this discussion. A health care primer was developed in a tri-fold color pamphlet form in order to help the physicians with their discussion. A significant effort was made to simplify the presentation of this complex issue. But, ultimately the level of discussion in the finished pamphlet requires an amount of education or literacy that makes it inaccessible still to many of their patients. This seems unavoidable to a certain extent because the health care system is at some point irreducibly complex and can only be simplified so far before the discussion becomes dishonest or meaningless. Rural Medicine in the Digital Era Project Date: 8/3/2009 Electronic medical records have been heralded as a cornerstone in the effort to eliminate waste and mistakes in medicine. Yet even today only a quarter of practitioners use EMR. The rates may be even lower in rural areas where practices are generally smaller and run on tighter budgets. This study will help to understand the key barriers to EMR adoption among rural primary care practitioners. Data was collected through formal and informal interviews with providers in Klamath Falls, OR. Through these conversations it became clear that while all of the providers were considering EMR, there were three types of barriers to adoption including financial, investigational and personal barriers. Given these barriers a low cost subscription EMR designed specifically for primary care practitioners would likely be the most beneficial design to encourage adoption of EMR among rural PCPs. Practice Innovation at Dunes Family Health Clinic: Are DFHC patients receptive to the idea of phone and email visits as alternatives to office visits? Project Date: 6/29/2009 Much of the excitement surrounding "Medical Home" style practice transformation involves streamlining patient-doctor interactions to make more appropriate use of time for all parties. One assumption called into question is whether doctor and patient need to physically see each other for a legitimate interaction to take place. If this is no longer the case, then the door is opened for new paradigms of patient visits, namely email and telephone visits. These services are currently scarce, primarily due to lack of reimbursement. But would providers and patients utilize these services even if they were reimbursed? This student sought to gauge patient sentiment at Dunes Family Health Clinic toward the idea of alternative doctor-patient encounters. A sample population of DFHC patients (n=189) completed a survey to answer these questions. Reimbursement without insurance: The cost of free medical care at the Cottage Grove Emergency Department. Project Date: 6/29/2009 The burden of loss of healthcare insurance has been a politically hot topic recently as our country’s leaders are struggling to find a solution to our failing healthcare system. I investigated the problem of uninsured patients seeking healthcare in the Emergency Department at the Community Hospital in Cottage Grove, Oregon, by analyzing financial records and determining total charges and reimbursement characteristics over several years. Comparison of data from 2005, 2008 and estimates for 2009 indicated a steadily increasing proportion of charges were made charged to uninsured patients. Furthermore, there was a coinciding steady decrease in the amount of charges made to patients with commercial insurance. These results indicate a shift in charges, which coincide with national trends indicating increased loss of insurance as unemployment levels continue to rise and other factors are contributing to patients’ loss of insurance. Through programs such as PeaceHealth’s “Bridge Assistance,” our regional healthcare systems are struggling to stay afloat as Congress continues to debate healthcare reform and the Federal Government continues to bail out major healthcare systems across the nation. Challenges to providing psychiatric care in Florence, OR– Is telemedicine an option for the future? Project Date: 4/27/2009 Mental health resources are already lacking in rural communities and by mid 2009, the two visiting psychiatrists who come to Florence every week will phase out their practices there. With this drastic change in psychiatric services, alternatives need to be explored in order to adequately care for the mental health patients in Florence. Additionally, it is important to investigate why these psychiatrists are leaving and what difficulties they have faced trying to practice in a rural setting. Interviews with two psychiatrists who currently see patients in Florence were conducted and literature search on telepsychiatry was done. It was found that there are financial, logistical, political and geographical reasons that make the practice of psychiatry in Florence, Oregon difficult. The departing psychiatrists believed their absence from the challenging patient population in Florence will create great stress on primary care providers, be traumatic for patients, and cause difficulty for children in school. There is a growing body of literature that supports the use of telepsychiatry as equally reliable at diagnosing and treating a variety of mental health problems while keeping patients out of the hospital and being cost effective. It is also financially feasible from a reimbursement standpoint with the passage of senate bill 24 in Oregon as well as a good source for the education of primary care providers. 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. Coming Out of the (Sample) Closet: Pharmaceutical Samples at Dunes Family Health Care, Reedsport, OR Project Date: 2/9/2009 Introduction: Pharmaceutical samples are commonplace in most medical offices in the United States, including Dunes Family Health Care in Reedsport, Oregon. The goal of this study was to assess the current inventory of drug samples at Dunes Family Health Care, and to survey the providers’ attitudes toward the presence of drug samples and industry detailers in the office. Materials and Methods: A comprehensive inventory of all drug samples was performed. The products were then further stratified by cost and therapeutic purpose. Voluntary surveys regarding pharmaceutical samples were distributed to all clinic providers with a license to prescribe medication. Results: There were a total of 2305 individual sample units in the clinic, which comprised 81 distinct drugs. The average retail cost per dose was $3.75 (range $0.25 - $21.00). The most common categories of medications in the office were those for asthma and hypertension, each accounting for 13% of the total number of distinct drugs. Survey results demonstrated a decrease in use of drug samples over the past five years. Lack of patient insurance was the most common reason for dispensing pharmaceutical samples. Most providers believe that drug samples save their patients money. Conclusion: Physician opinion regarding pharmaceutical samples varies among providers at Dunes Family Heath Care. There are numerous complex interactions at work when providing sample medications. The best way to ensure a positive outcome is a close relationship with one’s patients and a thorough knowledge of their medical history and social situation. Patient Perceptions of Rural Surgery: Can John Day's Blue Mountain Hospital compete with larger outside hospitals? Project Date: 12/29/2008 CONTEXT: Rural residents frequently have decreased access to surgical services. Consequences of this situation include increased travel time and financial costs for patients. There are also economic implications for hospitals as they may lose revenue when patients leave the area in order to obtain surgical services. Rural communities vary in size and distance from more populated centers. Since rural hospitals are located in varying types of rural communities, they likely differ with regard to the provision of surgical care. PURPOSE: To describe the differences between hospitals located in smaller versus larger rural areas regarding the provision of surgical care. METHODS: A 12-item survey instrument based on one previously used in a pilot study was mailed to a national random sample of rural hospital administrators (n = 233). Rural location was determined using rural-urban commuting area codes. FINDINGS: One hundred and eleven surveys were received, yielding a 48% response rate. Hospitals in larger rural areas had an average of 9 surgeons compared to 1 at hospitals in smaller rural areas. More administrators at hospitals located in larger rural areas viewed the ability to provide surgical care as very important to the financial viability of their hospital. CONCLUSIONS: Among rural hospitals located in communities of varying sizes there are significant differences in how surgical services are delivered and the financial importance of providing surgical care. Administrators at hospitals located in larger rural areas, more than in smaller ones, report financial reliance on their ability to offer surgical care and have significantly more resources available to do so. 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. 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. Identifying the Disparity: A Comparison of HIV Resources between Curry and Josephine Counties and Multnomah County Project Date: 9/8/2008 As with most health care resources, the HIV resources in rural communities are remarkably less available than more urban areas. This project attempts to qualify and quantify these differences and also attempts to provide an explanation for the differences in funding to these areas. Methods: The study uses interviews with patients, physicians and authorities from Josephine, Curry and Multnomah County Health Departments to identify key differences in these areas. It also uses analysis of the State of Oregon HIV Data and Analysis database. Conclusions: Although there are key differences in resources between rural and urban areas, the study concludes that the disparities are a product of supply-and-demand and a product of the algorithm used by the federal government for allocating dollars to these areas. It also concludes that there is incongruence in the incidence, prevalence and death rates of HIV in these areas, supporting the additional funding to urban areas. A Welcome Home: Needs Assessment and Projected Cost Analysis of the Addition of a Behaviorist to the Primary Care Home in Florence, Oregon Project Date: 9/8/2008 According to a 2002 study published in JAMA, “Most people in the United States want a medical home.” As the PeaceHealth Siuslaw Region Family Medicine practice makes plans to move forward with its version of a Primary Care Home, a needs assessment and a projected cost analysis were performed to determine the probable clinical and financial outcomes of adding a behaviorist to the care team. The design of this study was direct observation of the practice of one of the ten family physicians currently working at the PeaceHealth Family Medicine Center. At the conclusion of each working day, the patient census was analyzed; based on presenting complaints, chronic health problems and length of individual visits, we sought to determine which patients would have benefited from a consultation with a behaviorist. Based on average Medicare and Medicaid reimbursements for both physician office visits as well as Health and Behavior codes, we were then able to estimate the projected financial impact of these determinations. Our findings demonstrate that a behaviorist is a necessary and, in the worst-case scenario, a cost neutral addition to the Primary Care Home in Florence, Oregon n=1 or n=1 x 10? An Individual Perspective on Population-based Healthcare: A Case Study Project Date: 6/30/2008 In the United States, cardiovascular disease (CVD) affects 80.7 million (37.l%) individuals, is responsible for 869 thousand deaths per year, and generates an estimated $448.5 billion in annual economic costs. There are an ever increasing number of large epidemiologic studies, trials, and meta-analyses dealing with primary and secondary prevention of cardiovascular disease and its complications. New management and treatment guidelines are constantly generated and old ones discarded, updated, or revised, but the burden of CVD continues to increase. Oregon Health Division vital statistics show that Malheur County, location of my Rural and Community Health Clerkship, has a significantly higher than average death rate due to cardiovascular disease. The goals of this inquiry are twofold: one, to develop an understanding of Community Oriented Primary Care (COPC) within the context of a disease that is as relevant to populations in Malheur County as it is those in places like Orange County or Miami-Dade County and two, to evaluate some of the strengths and weaknesses of population-based perspectives like COPC on clinical outcomes for individual patients or the economics of healthcare. Hospice and End of Life Care In Tillamook Project Date: 3/17/2008 Hospice care embraces a philosophy of high-quality, comprehensive end of life care. My experience in Tillamook, OR made it clear that hospice is also, in fact, a very natural extension of the strong sense of community that exists in a small town. Through a series of home visits I learned about one Tillamook woman’s experience with hospice care at the end of her life, and via interviews with hospice nurses, the hospice medical director (my preceptor) as well as other users of hospice I found that hospice care in a small town-setting may have advantages over a larger city setting, however issues remain such as reduced use of hospice in rural areas and the financial vulnerability of small hospice facilities. I also discovered that this patient’s case may actually serve as an example for a more efficient use of health care dollars in the final months of life, and as a contrast to more common spending practices in our country’s current health care system. In my five weeks in Tillamook, I was exposed to multiple end of life issues with other patients in the clinic and in the hospital, and I found that more than any previous experience in my third year, the hospice environment and our home visits to a dying patient allowed me to find greater meaning and personal solace in my interactions with these other patients. Recruiting and Retaining Physicians in Coos Bay: Assessment of Medical Student Interest in Rural Medicine and Rural Physician Perspectives on Their Practice Project Date: 2/11/2008 Background. Coos Bay is a rural city on the southern Oregon coast that struggles to recruit and retain sufficient physicians. The purpose of this study is to assess medical student rural interest and Coos Bay physician perspectives as they relate to recruiting and retention. Methods. A literature search was conducted to identify common recruiting and retention issues. Physician recruiters and practicing physicians at NBMC were interviewed to identify unique issues and their commitment to this community. Finally, OHSU medical students were surveyed to assess their past and current level of interest in rural medicine. Findings. Key to physician happiness in is their practice. Most of the physicians interviewed are planning on retiring in Coos Bay. Medical student rural interest correlates with increasing student age, male gender, and rural upbringing. Specialties correlated with rural interest are family medicine, emergency medicine, obstetrics and gynecology, and pediatrics. Medical students showed increased rural interest following their rural clerkship. Conclusions. Successful medical practice is key to physician happiness and thus long term retention. OHSU’s third year rural clerkship is a great tool to increase interest in rural medicine. However, it can be further optimized by addressing housing issues, boredom, and misperceptions. Non-urgent Use of Hospital Emergency Services in Grant County, Oregon: The Impact of Primary Care Physicians Fleeing Rural America Project Date: 2/11/2008 Primary care physicians' covering the Emergency Department is almost exclusively seen in rural health settings. While these physicians rarely encounter problems of overcrowding and prolonged patient wait times often seen in larger cities, several issues arise that are somewhat more unique to rural health. One such issue is the direct relationship between the diminishing number of general physicians practicing in rural areas and the resultant overflow of non-urgent patients into the ED. Regardless, it is these same community doctors providing treatment for these patients creating what may be considered a vicious circle. This magnitude of this issue was explored via a questionnaire directed toward patients visiting the rural Blue Mountain Hospital Emergency Department in John Day, Oregon during a three-week period between February 2008 and March 2008. The results of this study showed that nearly 45% of all patients presenting to the ED during this time had initially attempted to address their health care needs in the primary care setting. These patients also encounter 30% higher costs for health care than their counterparts receiving care via their regular physician. Prenatal care resources available for low-income women in Grants Pass, OR Project Date: 12/31/2007 Adequate prenatal care is important for both maternal health and pregnancy outcomes. There are various social and behavioral risk factors for inadequate prenatal care, including low-income status. Therefore, it is imperative that resources are available for low-income pregnant women, in terms of access to prenatal care and patient education. According to census data, in 2000, 13.3% of the Grants Pass, OR population was below the federal poverty level ($17,170 for a family of 3 in 2007), and 37.4% were below 200% of the federal poverty level. This is in comparison to 11.6% and 29.6%, respectively, for Oregon as a whole. This study examines various prenatal care and education services available to low-income women in the Grants Pass area. Phone interviews were conducted with a coordinator at the Pregnancy Care Center, a county public health nurse, and a maternity case management nurse. In-person interviews were conducted with a member service manager at Mid-Rogue Independent Physician Association (MRIPA/OHP), and several patients. Printed materials available to patients were also obtained from Mid-Rogue IPA, a local county health office, and the Pregnancy Care Center. The findings suggest that a variety of prenatal care resources are available for low-income women in Grants Pass, but several barriers exist, including limited staff and funding for programs. Further examination of ways to optimize prenatal care and education at low cost, as well as potential initiatives to increase funding, would be beneficial. 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. The Oregon Prescription Drug Plan & the Uninsured and Underinsured Residents of Harney County Project Date: 12/31/2007 Senate Bill 362 is an amendment passed in the legislature in April, 2007 that expanded the Oregon Prescription Drug Plan (Ballot Measure 44). All Oregonians are now eligible for a free discount card for prescription drugs. Unfortunately, the bill did not include adequate funding to promote the program. Given the high costs of prescription drugs and the difficulty many Harney County residents have paying for their medications, this project was designed to increase local familiarization with the program and also to better understand the workings of the program. How well known is the program? How does it work and is there a true benefit? Is it possible for it to be sustainable in the long term? To answer these questions, staff members at the clinic and hospital were interviewed. Community resources to help patients pay for medications were evaluated, and interviews with the pharmacists in Burns, the director and assistant director of the OPDP, the executive director of the Oregon Pharmacies Association and a reporter from the Oregonian were conducted. In the end, two articles were written for the Burns Times Herald, the first informing citizens that the program is available with instructions to register. The second article focused on the details of the program, its funding and its future. Notifications were placed in several church bulletins in town, and the hospital, clinic and senior center were provided with resources to promote enrollment in the program. The benefits and drawbacks of the program were discussed with staff at the hospital and clinic so they could continue to educate patients in the future. The Unintended Model: Bringing Health Care Services to Rural Oregon Project Date: 10/15/2007 Santiam Memorial Hospital (SMH) in Stayton, Oregon is a unique small hospital with a rich history, influential present, and a hopeful future that strives to provide health care services to residents of the mid-Willamette valley in Marion and Linn counties. This qualitative study investigates how SMH administration, employees, and contracted providers have expanded their capacity for health care delivery in a challenging rural setting by cultivating successful staff and community relationships. The utility in exploring this unique situation includes elucidating strategies that may enable rural hospitals and providers to develop a greater capacity to meet the health care needs of other rural populations. The method of investigation primarily consisted of interviews and observation. I discovered that the ability of SMH and contracted providers to successfully deliver health care to their service population is tightly linked to local industry cooperation and successful community relations. Leadership Interviews Regarding Balanced Scorecards at Lower Umpqua Hospital Project Date: 9/10/2007 Quality improvement is very important in any setting, but especially in a small rural hospital where the surpluses are few, and any lapse in quality may affect community usage & therefore financial viability. The Balanced Scorecard has been proposed as an ideal way for small rural hospitals to strive for quality improvement through the idea that an organization’s mission/strategies and the execution of these are important factors in performance improvement. When Lower Umpqua Hospital joined 19 other rural Oregon hospitals it made the commitment to implement a Balanced Scorecard as way to measure performance against other such hospitals & strive for quality improvement. The purpose of this project is to assess the attitudes, perceptions & beliefs about implementation of a balanced scorecard amongst the leadership at Lower Umpqua Hospital, through key informant interviews. The 5 board members & 6 key administrative staff were interviewed; results were then summarized in an informant report to be used in future strategic planning & board meetings. 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? Community-based health insurance: an innovative solution for John Day’s un- and under- insured. Project Date: 3/19/2007 The community of John Day, Oregon has a number of un- and under-insured citizens who pay large amounts out-of-pocket on healthcare. Many wait to see an MD until they are sick and do not seek preventive care. They represent the fastest-growing group of uninsured in America: the uninsured who are employed and do not qualify for categorical eligibility for public programs (Medicare, OHP). Patients of the Strawberry Wilderness Community Clinic were surveyed regarding their demographics, insurance status, and opinions on a potential new healthcare plan. This plan, known as community-based health insurance (CHI) is used in developing countries and involves patients contributing a small amount of money per month ($10) to a risk-pool which can then defray healthcare costs among the community. There are certain limitations, and for John Day, the initial plan would only cover the cost of a clinic visit (no meds/labs). Nearly all un- and under-insured surveyed would be interested in this plan and willing to pay the proposed fee. Their concerns were about overuse of the system by a few. Physicians surveyed were all interested in the program, but had serious concerns about cost and too few patients for it to be economically feasible. Momentum for the plan would a barrier to implantation, as healthcare in the US seems to be “stuck” with a lack of innovation for new ways to ensure access. CHI would be one such way. Increasing High School Student Awareness of Health Careers in Union County Project Date: 3/19/2007 Although 20% of Americans live in rural areas, only 9% of the nation’s physicians practice there. Studies have shown that medical students raised in medically underserved areas tend to set up practice in such areas. Unfortunately, students from rural areas lack exposure to health care careers and practice opportunities. The purpose of this project was to develop and implement a rural outreach curriculum to help increase high school student awareness of health careers. The project goals were accomplished by visiting several high schools in Union County to give an interactive lecture designed to inspire students to enter the field of medicine. The project also included development of a student handout regarding age-specific OHSU and AHEC sponsored career exploration summer programs, available preceptorships, and available funding for high school students interested in a health career. The goal of the project is to reinforce the OHSU mission of attracting Oregonians to the School of Medicine and ultimately supplying all of Oregon with sufficient numbers of qualified health care professionals. Rural Healthcare Dialogue Project Project Date: 1/1/2007 Many private and public groups are currently involved in health care reform initiatives. The primary goal of this project is to decentralize and enrich the discussion of health care reform by engaging rural Oregonians in a conversation regarding their perceptions and expectations about healthcare, and to ensure that their opinions are relayed to the leaders of health care reform initiatives. Additionally, this project aims to foster leadership and activism among medical students and community members. Third year medical students will hold town-hall-style meetings in rural Oregon cities while on their required rural clerkships. These meetings will be open to the public, and provide education regarding the current state of health care in Oregon and the US, and discourse of several standardized discussion questions that focus on improved coverage and the finances of health care reform. Medical students serve as facilitators and document the general thoughts and sentiments for the group. Their results are communicated via a one-page summary document and one-page personal reflection document. At its conclusion, the findings will be shared with the Medicaid Advisory Committee, the Office of Private Health Partnerships, and the Oregon Health Policy Commission. So far, ten medical students have participated in the project, hosting meetings in eight cities. The findings to date are quite varied; however, several themes and lessons have emerged. First, many people lack understanding of the structure of our healthcare system, which creates a barrier to informed discussion. Second, the immigrant population is in favor of universal basic healthcare coverage while non-immigrants are generally opposed to coverage of non-citizens, and oppose tax increases to improve coverage. Third, students have responded positively to the experience, stating it has inspired them to continue participating in health care reform efforts. And last, rural health care providers believe that medical schools can influence future providers to practice in rural areas by recruiting students from rural cities, and by creating a rural medicine “fast track,” that specializes in training rural physicians. Rural Healthcare Dialogue Project Project Date: 1/1/2007 Many private and public groups are currently involved in health care reform initiatives. The primary goal of this project is to decentralize and enrich the discussion of health care reform by engaging rural Oregonians in a conversation regarding their perceptions and expectations about healthcare, and to ensure that their opinions are relayed to the leaders of health care reform initiatives. Additionally, this project aims to foster leadership and activism among medical students and community members. Third year medical students will hold town-hall-style meetings in rural Oregon cities while on their required rural clerkships. These meetings will be open to the public, and provide education regarding the current state of health care in Oregon and the US, and discourse of several standardized discussion questions that focus on improved coverage and the finances of health care reform. Medical students serve as facilitators and document the general thoughts and sentiments for the group. Their results are communicated via a one-page summary document and one-page personal reflection document. At its conclusion, the findings will be shared with the Medicaid Advisory Committee, the Office of Private Health Partnerships, and the Oregon Health Policy Commission. So far, ten medical students have participated in the project, hosting meetings in eight cities. The findings to date are quite varied; however, several themes and lessons have emerged. First, many people lack understanding of the structure of our healthcare system, which creates a barrier to informed discussion. Second, the immigrant population is in favor of universal basic healthcare coverage while non-immigrants are generally opposed to coverage of non-citizens, and oppose tax increases to improve coverage. Third, students have responded positively to the experience, stating it has inspired them to continue participating in health care reform efforts. And last, rural health care providers believe that medical schools can influence future providers to practice in rural areas by recruiting students from rural cities, and by creating a rural medicine “fast track,” that specializes in training rural physicians. Attempts to Document Healthcare Perceptions and Expectations of Scappoose Oregon Residents Project Date: 7/3/2006 This study intends to document the perceptions and expectations of healthcare in the rural community of Scappoose, Oregon for use in future healthcare reform. Despite multi-faceted aggressive public invitational postings no community members attended “town hall” style meetings. Further verbal invitations to local churches resulted in five parishioners who perceived most to least significant healthcare issues as being; 1)unavailable/inadequate health insurance, 2)inadequate access to providers, 3)lack of transportation options to an urban center and 4)treatment plans unrealistic in a rural setting. Their expectations included reform to be driven at the federal rather than state level and that such reform include adequate funding. Overall, the failure to generate adequate community participation in this study must be considered in all future efforts to understand healthcare in rural Oregon. Nuclear Medicine in Reedsport, OR. Myth or Reality? Project Date: 1/2/2006 As the needs for nuclear studies are expanding in Reedsport, Oregon, the Lower Umpqua Hospital wants to introduce a gamma camera to be a part of their imaging facility. Being a small 22-bed critical access hospital for the area of 8,000 people puts certain financial restrictions on the scope of services the hospital can provide. Mainly a feasibility analysis for implementation of radionuclide studies into the hospital operations, this project attempts to evaluate the needs of the community and financial viability of the new imaging service. The potential barriers to entry, ways to mitigate them, and functional advantages of the hospital were explored. The analysis confirmed the immediate needs of the community for nuclear studies and supported the far-reaching plans to expand the scope of hospital services in the future. Pro-forma financial statements based on the realistic assumptions showed potential ability to break even on operations but inability to get any direct return on investment. The findings were shared with the hospital administration, staff of the radiology department, and physicians from the Dunes Family Health Care clinic. A pro-forma spreadsheet for profitability analysis was created for the hospital administration. Further research on how to make it profitable is suggested. 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. Recruitment of rural physicians: the challenges of a hospital and a private clinic in Klamath Falls, Oregon Project Date: 9/12/2005 A present and future healthcare concern facing the United States is the shortage of physicians practicing in rural areas. Doctors disproportionately prefer urban-suburban practices, and this makes the recruitment of rural physicians a challenging task. This report documents the hospital and clinic recruitment process of the rural town of Klamath Falls, Oregon. Data were gathered from interviews with the physicians involved in the recruitment process at the Klamath Falls hospital and private clinic, and from published journal articles. The strategies for recruiting included hiring a recruiting service and establishing a local residency program and expanding medical student clerkship programs. The recruitment incentives the hospital and clinic offer to candidates include higher salaries, assistance in setting up a practice, establishing a clientele and assistance with spousal employment. Besides attracting physician candidates with the beautiful environment, physicians are drawn to Klamath Falls because of the low cost of living, the broader scope of the medical practice, the casual lifestyle and the lack of traffic congestion. Nonetheless, the recruitment is low due to the complaints of increased on-call hours, low reimbursement and no educational loan support. I recommend two broad strategies for increasing physician recruitment. First, Klamath Falls should emphasize its stunning natural surroundings. More importantly, Klamath Falls should increase its efforts to reach out to rural training programs nationwide. A new way to save on prescription drugs? Educating the physicians and Medicare patients of Klamath Family Practice on the Medicare-Approved Drug Discount Cards Project Date: 1/3/2005 The cost of prescription drugs continues to be a major health issue in the United States, especially for elderly patients on Medicare. The goal of the project was to educate the physicians and Medicare patients of Klamath Family Practice about Medicare-approved drug discount cards so that patients could take maximum advantage of the offered savings. First, the project was designed to interact with Medicare patients and try to understand how they currently try to save money on prescription drugs and determine how familiar they were with the new Medicare-approved drug discount cards. After determining that the physicians and patients knew very little about this new program from lack of available information, the program was thoroughly researched to determine if Medicare patients would benefit from these new discount drug cards or not. The physicians were educated about the new program, and the final product of this project was the development of a poster for the lobby and a brochure to educate Medicare patients about this new program and help them save money on prescription drugs. Financial Burden on Lower Umpqua Hospital (LUH) Due to Traumatic ATV Accidents of Uninsured Patients’ During 2004 Project Date: 1/3/2005 Reedsport, Oregon is located within the Oregon Dunes National Recreation (ODNR) area, a vast landscape of sand dunes that is used, among other activities, for riding all-terrain vehicles (ATV). Riding is open all year long, but there is a four-day event at the end of July known as DunesFest during which riders come from all over the nation to race their ATV’s and party. Alcohol is not strictly regulated on the dunes and, this, combined with periods of heavy ATV traffic, results in a significant number of trauma accidents throughout the year. Given that ATV riding is an expensive sport, nearly all riders could afford insurance. However, many of those that are injured are either inadequately insured or, more likely, do not have health insurance. This puts a great financial burden on LUH, as one of its very important functions within the community is acting as a “safety net” hospital, treating many uninsured patients’ for unforeseen illness and acute injury. The added impact of expensive ATV traumas that go unpaid compromises the ability of the hospital to act as a safety net. This research showed that uninsured ATV traumas were costly to the hospital during 2004 and that during the month of July the amount unpaid was a significant percentage of the total billed. Additionally, it was shown that July, August and September were particularly hard hit by uninsured ATV trauma and that most of the patients were either from out of town or from a different state. Finally, the results were used to formulate a plan to contact a state legislator to discuss the feasability of mandating accident insurance for all ATV riders riding within the ODNR area. 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. Analysis of drug sample use at OHSU Scappoose Family Practice Clinic Project Date: 8/9/2004 Prescription drug costs are a growing concern for many patients seeking medical care in the United States today. One recent study predicts that drug expenditure growth should continue to outpace the growth in overall health care expenditures and the growth in the U.S. economy. Currently many physicians use free drug samples provided by the pharmaceutical companies to provide medication to their patients. This study attempted to analyze the use and opinions of drug sample resources from three practitioners in a rural OHSU primary care clinic in Scappoose, Oregon. The design was to randomly select 101 instances in which drug samples were given out to patients and analyze as to which physician prescribed the sample, total costs saved for the patient versus local pharmacy costs, and compare with the insurance status of the patient. In addition the three practitioners from the clinic were independently interviewed concerning their views of drug samples to be compared with the actual free sample prescribing habits. The overall objective of this project is to determine if there is any pattern to the prescribing of free drug samples from the clinic and to investigate alternatives available for patients who are not able to afford their prescription drug costs. 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. Uncovering Available means to reduce prescription drug costs, and improving patient access to this information Project Date: 5/10/2004 Increasing prescription drug prices place significant financial strains on numerous segments of the population. The reduced medication compliance that results from this reality adversely impacts both the directly involved individuals health and the overall healthcare system. While this is not a problem with an easy solution, numerous programs currently exist that could benefit those less then able to pay. These programs are underutilized, however. Using mainly discussions with providers, obervation patient questions, and internet seraches, the following resource categories were discovered: PAP programs, Medicare drug cards, and miscellaneous state-specific programs. Additionally, a previous student handout on the use of overseas pharmacies was consulted. Though the handout's recommendations were technically illegal, the fact remains that millions of Americans do obtain their medications at discounted rates from overseas pharmacies - without real FDA enforcement. As such, an attempt was made to help make the practice as safe as possible. From all this information a handout was created, inteded to maximize patient self-sufficiency and benefit while minimizing resource costs. Medical Billing in the Emergency Room in Reedsport, OR Project Date: 3/29/2004 Medical billing is an essential aspect of a physicians practice. Determining the appropriate code entails a subjective evaluation of the complexity of a visit. Accurate coding requires a delicate balance between maintaining financial viability and avoiding bureaucratic intervention. In this report, I analyzed the current billing trends in the ER at Lower Umpqua Hospital in Reedsport, OR. 115 ER visits from 11 physicians were reviewed and billing codes were assigned according to the 2004 CPT guidelines. The actual codes were then collected and compared with the evaluated codes. On average, physicians billed for 86% of the total potential billing. This equates to 145 under-billing in the ER, which results in decreased revenue for the hospital. Financial burdens to rural health care systems in Oregon have resulted in the loss of some services and even the closing of hospitals. Improved understanding and application of the current CPT guidelines for medical billing can help stabilized financial viability and ensure continued health care in rural communities. Lack of Health Care benefits Project Date: 3/29/2004 In the past 6 weeks I have been very fortunate to work with Dr. Lance Loberg, Medical Director for NW Human Services community clinics. Because of the comprehensive care provided through this agency, I had the unique opportunity to see patients at the West Salem Clinic, Total Health in Monmouth and H.O.A.P. Mental Health clinic for the homeless and underserved. The experience of being immersed in the lives of such diverse populations enabled me to learn their different interests and life dreams as well as their common fears and frustrations. In a short time, it became frightingly apparent to me how many members of the Salem communty were living with diabetes and felt like they were fighting against more barriers than they could handle. With the decline in health care benefits and services, most patients had lot their mental health and prescription coverage. This left them using unavailable financial resources to provide for medical care and medications. Combined with the current unemployment rate and the increase in costs of living, many hard working people found it necessary to choose between their health and the basic welfare of their family. Views on Medicare Reform Bill from people who it affects most Project Date: 11/10/2003 Over 35 million US seniors today rely on Medicare as their primary health insurance. These seniors have very few/no options for prescription drug coverage, and none of these options are part of a routine Medical benefit package. In an attempt to address this situation, this year the Medicare Prescription Drug Improvement and Modernization Act of 2003 was passed by the U.S. Congress. The intent of this bill was to offer seniors a limited drug benefit as well a competitive choices in health plans, a number of reimbursement increases for physicians, and many other changes to Medicare in general. The intent of my projects was twofold. My first objective was to determine how well the seniors understood this new legislation and what their general view of it was. Secondly, I wanted to determine the legislation's impact on the sample of elderly Medicare recipients from the Florence, OR family practice clinic where I worked. A phone and office interviews were conducted to examine these issues. The results indicated of an almost even 48% to 52% division in support for and against this reform, repectively. However, the understanding of the details of this legislation was lacking for a majoirty of seniors. It was also evident, that if the sample is representative of the Medicare recipient community in Florence, at least 40% will not see any relief in their current prescription medication costs. Assessment of OHP Changes on OHP Patients at Dunes Family Health Care Last Five Years Project Date: 7/7/2003 The Community Health Improvement Partnership (CHIP) provides a vehicle that allows local health care and public leaders and residents to collaboratively assess health care needs of the community. A result of this collaboration revealed a perceived health resource problem of lacking affordable health care. A project was undertaken to assess this perceived need of the community and evaluate what impact changes in the Oregon Health Plan (OHP) may have had on OHP patients at the Dunes Family Health Care (DFHC) clinic. Results of the analysis reveal the percent of Reedsport Service Area (RSA) population below Federal Poverty Level and require health assistance is well above State and national average. Analysis of DFHC patient data reveals the OHP patient base has remain steady at about 15 percent of total patient population for the past four years, which is higher than the national Medicaid average of 12.7 percent. OHP reimbursement at the DFHC has steadily increased in the past four years with a possible slight projected drop in 2003. The perceived low-income health assistance needs in the RSA is supported by socio-economic and DFHC clinic data. However, changes in the OHP in the past four years have not affected the number OHP patients or their frequency of office visits at DFHC. The DFHC OHP population has averaged 3.5 annual visits per patient compared with 1.5 visits per non-OHP patients in the past four years. This difference in number of visits may justify further evaluation as the debate continues over cost, level of coverage, and eligibility of the OHP. Strategies for Coping with Rising Medication Costs. Project Date: 3/24/2003 Rising prescription medication costs pose an acute financial burden on the lives of rural Oregon's senior citizens. This project is designed assess patient difficulty and provider awareness with the issue and provide education materials. Short surveys were given to senior patients with questions concerning income, costs of medications, insurance coverage, compliance, and strategies used to lower costs. Additionally, to assess physician knowledge of cost issues, a quick, "off-the top-of-your-head" quiz concerning prices of three common medications at different doses. Focusing in on pill-splitting, an computerized chart review was used to identify potential savings from implementing pill-splitting techniques for one common medication. Finally, both patient and physician education handouts detailing cost saving strategies were developed and distributed, along with a common medication price list for providers. The Community Health Improvement Partnership (CHIP) and Reedsport, OR: A Prescription Drug Assistance Program for Seniors. Project Date: 3/24/2003 In cooperation with Office of Rural Health at Oregon Health & Science University, the small rural town of Reedsport, OR has initiated a process of evaluating and addressing the community healthcare needs through the Community Health Improvement Partnership (CHIP) (McGinnis, 1999). The goal of the project outlined here is to use some of the information and infrastructure that has been laboriously compiled through the efforts of numerous people within and outside the community to address one of the major healthcare disparities identified through the CHIP process. Several students have worked as part of the CHIP process in Reedsport, following the project through its different phases (Morgan, 2002; Kerr-Valentic, 2003). These past projects have described the coalescence of the CHIP council, its decision-making, and the identification of the community healthcare needs. The next step in the process is the design and implementation of specific programs to address those community needs. This project proposes one such program, the creation of an organized prescription assistance program for seniors. Prescription Costs in Tillamook Oregon Searching for Keys to Education & Compliance. Project Date: 3/24/2003 Background: In the 4 years preceding 2002 medication costs increased at a rate of about 30% yet over that same time frame social security benefits increased only 9.4%. How do the ever-increasing cost of medications affect the lives of those who take them? Do these increase costs have an effect on patient compliance? Do people know about programs that are available to help low income seniors with the increasing costs of medication? These questions were attempted to be answered. Methods: An anonymous questionnaire was obtained in two locations in Tillamook, OR. Total surveys returned were 58. An attempt was made to correlate medication expense with patient medication compliance. An additional attempt was also made to compare the difference in response between the in-clinic and out-of-clinic settings. Results: It was determined that as monthly costs rose patient compliance decreased. The average patient expenditures for medications was $162 while the average for the self-reported non-compliant patient was $276. There was about an equal percentage of patients in the clinic and out who knew about programs from drug companies but in the clinic only 38% wanted more information on these programs while outside the clinic (at the senior center) 88% of patients requested more information. Conclusions: As medication expense rose compliance decreased. This shows a need for decreasing the overall cost of medications. Also patient education goals are not being met. Only 50% of patient were knowledgeable about reduce cost drug programs. This leads us to conclude that our education methods at present are insufficient in office and desperately inadequate in the general community. It is the feeling of the author that informational material should be better displayed in the clinic and a program be established to make at least some basic information available to those in the general community. This information that might be made available was reviewed under the programs portion of this paper. Community Response to Loss of Pharmacy Benefits for Patients with Schizophrenia in Lebanon, Oregon Project Date: 2/10/2003 Recent budget cuts have led to the loss of pharmacy benefits for certain Oregon Health Plan patients. People with schizophrenia were identified as a group particularly vulnerable to deterioration and increased complications without medication. The purpose of this project was to examine the resources available to address this crisis in Linn-Benton counties, and Lebanon specifically. Community response included creation of a generic formulary and a medication assistance program, despite lack of government funding. Resources in Lebanon for this population are substantial. The primary shortcoming was dependence on pharmaceutical company patient assistance programs for patients who require atypical antipsychotic medication. Managing the Cost of Pharmaceutical Drugs in Small Town Oregon Project Date: 2/10/2003 Increasing prescription drug costs are becoming a financial stressor for patients and a burden for office staff. Patients have been reporting to doctors and office staff that they cannot afford the prices of their medicine, thus choosing between buying their medicines or other basic necessities. Some patients report that they have been missing doses of their medicine or not purchasing it all together simply due to cost. Besides the obvious negative health outcome this has for the patient, it also frustrates the health care providers hoping to manage a patient's particular health problems. Furthermore, office staff often finds themselves trying to help the patient apply for social assistance programs or get in touch with other resources. Ultimately, this consumes a significant amount of time and resources for both the doctors and office staff. Furthermore, patients often have difficulty understanding ways in which they can cut their drug prescription costs, and consequently rely on office staff for help. To address this issue, a survey of Bay Clinic patients was performed to discover what patients currently spend per month on their medicines, how much money they save using office samples, and what cost saving measures they currently use to help control costs. Ultimately, after analyzing the data, it was determined that a simple piece of literature could be developed which could help the patient learn of ways to reduce their prescription drug bill. Increasing Access And Affordability Of Prescription Drugs For Medicare Patients In A Rural Health Setting Project Date: 2/10/2003 Affordable access to prescription medications is a problem for many elderly patients in the United States. For elderly persons living in rural communities the problem seems to be even greater - there seems to be a certain negative synergy between being elderly and living in a rural setting when it comes to drug access. To top it off, rural health clinics lack the typical interdisciplinary teams seen in some urban clinics. By not having a social worker or volunteer who might help patients decipher drug discount programs, health care workers are called to wear many hats, all in a nine-to-five workday. This project aimed to identify what characteristics about elderly rural patients make them vulnerable to decreased access to affordable drugs. The next step attempted to identify what one rural health clinic was doing to increase access. Extensive research was conducted on the available programs for cost savings on prescription drugs. Finally, a revised program was designed to increase access and affordability for patients and hopefully increase efficiency for the health care worker. Methadone Maintenance Therapy: An evaluation of health benefits, cost-effectiveness, social impact. Project Date: 12/30/2002 BACKGROUND: Injection drug use in the United States is a significant cause of morbidity and mortality, increased health care costs, and criminal behavior. While methadone maintenance therapy (MMT) reduces criminality, health care expenditures, and morbidity and mortality among injection drug users and the general population, economic, social and political barriers prevent its universal funding. The purpose of this review was to examine the cost effectiveness, effect on morbidity and mortality, and effect on criminality of MMT in order to help determine whether MMT should be covered by health care plans. METHODS: A literature review was conducted to determine the cost effectiveness of MMT with respect to morbidity and mortality, criminal behavior, and survival as measured by overall survival and quality-adjusted life-years. RESULTS: Among a population of drug users and non-users, methadone maintenance treatment leads to significantly decreased health care costs, decreased morbidity and mortality, and has a cost per quality-adjusted life-years that is well below many other accepted medical interventions. CONCLUSIONS: Methadone maintenance treatment is cost-effective on the basis of commonly accepted criteria for medical interventions. Funding MMT is a cost-effective investment by health care plans that should lead to long term monetary savings and increased quality-adjusted life years among the entire population. 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. Impact of Surgery on Lower Umpqua Hospital, Part II: Provision of Obstetrical Services, a Community Needs Assessment Project Date: 11/4/2002 Following an era of business success, growth of faculty, and outstanding service, Lower Umpqua Hospital is now searching to hire a general surgeon. A prior study examined the economic impact of surgery at the Lower Umpqua Hospital (Melvin, 2001). In this project, we assess the community impact of services provided by surgery. In particular, the Lower Umpqua Hospital has recently announced it will not provide routine obstetrical care (Vail, 2002). The Dunes Family Health Care also announced it will not provide third trimester prenatal care (Law, 2002). Community demographic and socio-economic climate, and health care services currently provided are described. A needs assessment describes the current market share, community vital statistics, and economic implications. Finally, the impact of cessation of services is addressed in terms of community reaction, a call for community response, and case-scenarios. Type 2 Diabetes Mellitus in Florence, Oregon. The Cost of Disease Management Project Date: 12/30/2002 Diabetes Mellitus is a disease marked by several pathophysiologic consequences including hyperglycemia and eventual end organ disease secondary to altered physiological states. Type 2 Diabetes (DM2) is manifest by insulin resistance leading to eventual impairment of insulin secretion by the pancreas and increased glucose production via gluconeogensis in the liver. The prevalence of DM 2 is rising in the US and is expected to continue to rise rapidly due to the occurrence of obesity and reduced activity levels. Oral hypoglycemic drugs are a major line of therapy in the treatment of DM 2. Many people diagnosed with this health challenge in Florence, Oregon are part of a population that might have limited assistance accessing drug therapies due to the limitations of traditional Medicare coverage. As many patients must contribute to or are completely responsible for the cost of medication and these drugs reduce long-term complications, the patients encumbered by this disease are in essence buying their long term health. Paying for Prescription Drugs in Newport, Oregon. An analysis of prescription drug expenses and the methods of payment for patients at Pacific Internal Medicine Project Date: 9/23/2002 Prescription drug costs create a financial burden for many patients nationwide. This study attempts to assess this burden for patients at Samaritan Pacific Internal Medicine (SPIM) of Newport, Oregon. A survey of patients was conducted to examine how they pay for pharmacotherapy (i.e. insurance, out-of-pocket payment, government assistance), the monthly expense of prescription drugs, and what percentage of the patient population believes that prescription drug costs are a barrier to treating their medical conditions. This study also evaluated the methods employed by SPIM to assist their patients in obtaining drugs at discounted rates; this analysis was performed through observation and informal interviews of members of the medical staff. The results of the survey indicate that many do consider the cost of prescription drugs a barrier to healthcare, particularly patients with net monthly incomes below $1500, those paying over $50 per month for prescriptions, and the uninsured. Analysis of office practices to assist patients in managing prescription costs demonstrates that SPIM works diligently to educate patients about opportunities to receive discounted drugs and to assist them with the application process required to receive them. Prescription Medication Patient Assistance Programs in Harney County, OR: Development of an Efficient Application System Project Date: 8/12/2002 The access to prescription medications is an essential component of complete health care for our patients. Increasing drug costs, increased utilization, and the lack of bulk medication purchasing for the uninsured populations makes medication acquisition a growing problem, especially in rural areas. The patient population at the High Desert Medical Center in Burns, OR was evaluated for eligibility for existing pharmaceutical manufacturers’ patient assistance programs. Results indicate that 100 patients were receiving benefits, while up to 509 may be eligible. The labor required to complete applications and to distribute medications was cited as a barrier for efficient utilization of these assistance programs. Software was ordered and installed to help the clinic staff in administration of these programs. A patient handout summarizing the various options for obtaining affordable medications was constructed and published (http://www.geocities.com/mmacht/medhelp.pdf) so it could be used by patients and health care providers throughout the state. Further sources of aide, including grants from the Rural Health Foundation, were discussed with clinic staff. The handout was observed during the final three days of the rotation, and found to be extremely successful in educating patients and staff about the various assistance options, involving patients in the administrative process, and encouraging more eligible patients to seek assistance. Starting a Rural Family Practice and Staying Afloat. A case study in Hermiston, Oregon. Project Date: 8/12/2002 This case study explores the challenges met by physicians starting a rural family practice. Dr. Bolanos-McClain and Dr. McClain started their clinic 1' year ago with 4 patients in Hermiston, Oregon. Today, they have between 1,200 and 1,300 patients. They work approximately 35.5 hours per week more and earn up to $90,000 less than the national average for private family practices in 1997. When interviewed about his practice, Dr. McClain stated that "there are really good days and bad days, good weeks and bad weeks, with extremes of both." This brings into questions whether physicians will continue to be able to serve these communities while working under these conditions. Emergency Eminent: Dunefest 2002 Project Date: 7/1/2002 OBJECTIVE: To assess the emergency preparedness of the Umpqua Lower Hospital's Emergency Room, EMS system, and Operating Room for Dunefest 2002. To offer suggestions for next year's Dunefest based on the problem areas identified through this assessment. METHODS: Dunefest planning meetings, sponsored by the Reedsport Chamber of Commerce, were attended. Records of past Dunefests were reviewed, including ER and EMS logs, and these were discussed with personnel who were present those years. An assessment was made concerning the state of preparedness for Dunefest 2002. After the event, preparedness was reassessed based on experiences in on ambulance rides, in the ER and OR, and through discussion with hospital and EMS administrators. RESULTS: Chart review and previous Dunefest experience from 1999, 2000, and 2001 dictate the importance of increasing law enforcement and decreasing the number of people camped at the event site. This year, EMS was well prepared and easily handled their responsibilities. Increased staffing in the OR allowed for the multiple orthopedic cases that were expected; however, some supplies were low or unavailable. The ER physicians were challenged in keeping up with the number of emergencies resulting from the event. The hospital is most likely losing money through the event, due to the increased influx of uninsured patients. CONCLUSIONS: This year's preparation was adequate. An internal audit is recommended to determine whether Dunefest is resulting in a net loss in the hospital's finances. The Dunefest committee for 2003 should consider a fee for event insurance to offset the costs of treating the uninsured accident victims. The OR and ER should be stocked at least three days prior to the Dunefest events. A backup plan should be devised for overburdened ER physicians during the event. Coding Practices in a Rural Oregon Health Clinic: An audit report on acute care visits. Project Date: 3/25/2002 This study is intended to elucidate the general coding practices for an acute evaluation and management (E/M) encounter at a rural pediatric clinic. It entails the external audit of progress notes for acute E/M encounters during the first few weeks of one of the busiest months of the year for acute pediatric care, and will identify any flaws in the coding practices for such encounters. The basis for this study is to provide valuable feedback on coding practices and whether those practices are in compliance with established rules and guidelines set up by the Health Care Financing Administration (HCFA). The practice of over-coding or under-coding will be specifically addressed, and suggestions will be made about possible changes in documenting habits that more accurately reflect a fair and equitable assessment of the level of care provided for an acute E/M encounter. Are New York Times headlines a reality in Reedsport, Oregon? Project Date: 3/25/2002 According to the American College of Physicians-American Society of Internal Medicine, physicians in general practice stand to lose approximately $8,000 each this year. In Oregon the 2001 Medicare cuts may translate into an overall loss of $14,700,000. For Oregon physicians this problem is made even worse by the fact that the costs of delivering health care in Oregon continue to rise each year. Malpractice premiums alone have increased by double digits for most physicians in Oregon, up to 56% higher for some Oregon physicians. In addition, approximately 50% of Oregon family physicians are age 50 and over. The high cost of providing medical care and poor reimbursement rates may trigger the retirement of many of these older physicians. A national survey has shown that before the Medicare cuts, approximately 80% of physicians were considering leaving or scaling back practice. If the above is true this could potentially create a shortage of access to primary care for Medicare patients both nationally and in Oregon. Who Will Catch the Babies? The Impending Medical Liability Crisis in Grant County, Oregon Project Date: 3/25/2002 With the rising cost of medical liability insurance premiums, it is becoming unaffordable to practice obstetrics in Grant County, Oregon. One of Grant County's five physicians has already decided to quit practicing obstetrics and if premiums increase much more, it is likely that the remaining four will follow the same path. The result will be additional problems with access to care in rural communities. Expecting mothers in Grant County will have to drive over two hours for obstetrics care. In this paper I will look at how other states in the country are dealing with this problem and what the OMA and AMA are recommending for further action. With this informaiton, I will assess what the physicians and residents of Grant County can do to initiate change to avoid a medical liability crisis in Oregon. Mental Health Care in Tillamook County Project Date: 2/11/2002 Despite a popular perception that rural America is a wholesome and healthy place to live, many studies have shown that this is not necessarily the case. Although approximately one forth of all Americans are rural residents, almost one third of the nation's poor and 29% of the nation's elderly reside in rural areas (Human, et al. 1991). Rural residents are also disproportionately affected by chronic illness, are more likely to live in substandard housing, and have more days of disability and missed work (Murray, et al. 1991). All of these problems - advanced age, poverty, and chronic illness - predispose rural residents to a higher risk of mental illness, yet research done over the last decade indicates that this same population is less likely to receive adequate mental health care than urban residents (Badger, et al. 1999). Studies have shown a number of reasons for this. First, rural residents are less able to pay for mental health services. Many rural areas have remained economically depressed since the late 1970's following a decline in the farming, manufacturing, and natural resource based industries such as mining and logging. Rural residents have a higher rate of uninsuredness and, because they are more often among the ranks of the working poor, are less likely to qualify for programs such as Medicaid (Human, et al. 1991). Second, rural areas suffer from a profound lack of mental health care providers. For instance, 77.5% of counties with fewer than 100 persons per square mile lack a single registered psychologist as compared to only 2% of counties with a density of greater than 400 persons per square mile (Murray, et al. 1991). Another study found that only 10% of outpatient psychiatric clinics are located in rural areas (Abraham, et al. 1994). As a result, rural patients with mental illness are forced to seek help from their primary care physicians. EMS in Harney County: Benefits of Transition from a City-run, Volunteer Fire Department Based Program to a Hospital-owned Program with Paid Personnel Project Date: 2/11/2002 This report is a review of the changes made in recent years to the Emergency Medical Services (EMS) program in Harney county. In the past the City of Burns has been the responsible party for provision of EMS; the program has been run under the auspices of the Fire Department. For the most part EMS personnel have been voluntary and the levels of training among personnel have been quite varied. Rather than being run as a business, the service was run as a volunteer-based program. There were no full-time paid personnel whose responsibility it was to keep the service functioning at a level that provided a quality service to the public as well as keep the service solvent economically. Over the long run the service was a drain on the resources of the community: the service cost a great deal of money to provide and the City was still unable to maintain needed equipment and keep appropriately trained personnel. Two years ago Harney District Hospital took over the EMS program, hired a full-time paramedic to run the service, and with the help of the experience of the hospital administration and the new director began to bill appropriately, look at ways to qualify for government funds for purchase of equipment and education of personnel, and overall made changes directed at running the service as a business. Through the changes that have been made the quality of service has been greatly improved and the EMS program has become solvent. The following discussion is intended to examine the changes that have taken place and consider whether or not this program may function as a model for similar communities to improve their EMS systems. Comparisons of the Medical Office Staff Needs in Rural Hermiston Oregon Versus Urban Portland Oregon Project Date: 2/11/2002 This study sought to determine the differences between the staffing needs and availability of trained office staff in the rural Hermiston Oregon area versus the urban Portland Oregon area. The design was to survey practices in Hermiston and Portland metropolitan areas and compare the results. It was found that the physicians in Hermiston preferred staff with a higher level of education and had a harder time finding trained office staff of any level of education to work in their offices, where as the Portland clinics preferred staff with a lower level education and had less difficulty finding staff of any educational level. The report discusses that more research is needed in the area to better identify needs and gives some recommendations on recruiting better trained office staff. How Residents Of Baker City Choose Their Primary Care Physicians. Project Date: 1/2/2002 The purpose of this project was to evaluate how people in Baker City choose their primary care physicians. It was thought that information about how people choose their doctors could be beneficial to rural physicians seeking to increase their patient loads. Selected patients in Baker City were asked to complete a questionnaire about how they chose their doctor. Results of the study revealed that residents of Baker City rely on recommendations from trusted sources about as much as those in previous studies did. In addition, Baker City residents rely more on personal knowledge of their physicians and whether insurance will cover the doctor visits, than did patients in previous studies. This is thought to be due to the higher percentage of Medicaid patients in rural areas and to the nature of a smaller community where patient might be more likely to know their physician outside of their medical role. An Evaluation Of U.S. And Canadian Online Pharmacies For Medicare Patients At Klamath Falls. Project Date: 1/2/2002 Approximately half of the patients seen at Klamath Family Practice Center are on Medicare, which does not cover outpatient prescription drugs, and many of these patients struggle with high costs of their prescription medications. This study evaluates 6 online pharmacies, 2 in U.S. and 4 in Canada in terms of their prices and selections in comparison to Klamath Falls Safeway Pharmacy. Results indicate that U.S. online pharmacies offer little or no savings over local prices. In fact, many of the drugs they carry may actually cost more than at local pharmacies. Out of the four Canadian online pharmacies evaluated, three offer significant savings of 24.10-30.80% over local prices. The fourth Canadian pharmacy offers a much lower 4.60% saving mainly due to its high dispensing and shipping fees. In Conclusion, www.canadameds.com and www.canadiandrugstore.com are found to be highly recommendable online pharmacies for their low prices and good selections on prescription medications. Eye Health Care In A Coastal Oregon Community. Project Date: 1/2/2002 This study sought to determine whether patients in a primary care clinic (Bay Clinic of Coos Bay, Oregon) received regular eye examinations as recommended by the guidelines of the American Academy of Ophthalmology (AAO), and whether their age, insurance status, and/or need for corrective lenses influenced how often they had regular eye exams. Brief questionnaires regarding utilization and insurance coverage of basic eye care services were distributed to Bay Clinic patients between January 10 and February 1, 2002. One-third of those surveyed were age 65 or greater; 97% of these required some vision correction, and 91% had eye exams within two years of the study. In contrast, only 77% of patients younger than 65 required lenses, and only 77% had exams within the past two years. Type of insurance coverage had little influence on time of last exam, with 79% of privately insured, 81% of publicly insured, 100% of those with public insurance privately supplemented, and 100% of uninsured patients having exams at most two years ago. Need for corrective lenses had significant effect on time of last exam: 90% of those who required vision correction had exams within two years, while only 48% of those not requiring lenses had exams over the same period. The report also discusses the importance of regular eye examinations and the guidelines of the AAO. Overseas Pharmacies Online Cutting Prescription Drug Prices. Project Date: 11/5/2001 Troubled by stories of patients who had chose to go without medications because the cost was too high and after the frustration of having prescribed a medication only to find out that it was not covered by a particular insurance company's formulary, I decided to see if there may be a way to purchase drugs cheaper overseas. Studies have noted that Americans regularly pay up to twice as much as Europeans and Canadians for the same drug, and my preceptor had mentioned that a few of his patients had purchased discounted drugs across the border in Mexico and Canada. I was curious to have an idea of what type of patient would benefit most from lower prescription drug costs and what the patients' perspective was on why drug costs were so high. I offered a questionnaire to patients over the course of a week in the clinic. Thirty-five patients responded to the questionnaire and the results are detailed in Table 1. The questions were not designed to provide hard data, but rather to offer a subjective framework and personalize the project for the community. The average age of the patient was 57, with oldest being 90 and the youngest being 18. There was an even distribution among income categories. However, the common denominator appeared to be in answering the question that asks if they would benefit from lower prescription drug prices. Invariably, the answer was "yes". One frustrated patient wrote, "Please tell me if there is anything that does not cost both arms and both legs." The elderly patient with a mid to low income appeared the most affected by a long list of medications and little or no supplemental insurance to cover the bill. Also interestingly, most did not choose to answer the question that asked why the cost of drugs is so high in our country. The question fell at the end of the survey and may account for why some chose to skip it, but more likely a blank answer indicated that the respondent did not know the answer to the difficult question. In the recent years, the pharmaceutical industry has been by far the most profitable industry in the country (2,3). Drug companies are beginning to offer indigent programs for patients that meet an income level, on average, of less than 15,000 dollars per year. These are praise-worthy programs and my preceptor and his staff have worked hard to identify patients who fit the appropriate profile. For instance, Merck offers up to three drugs completely free of cost for three months when the proper application has been completed. While programs such as these are certainly beneficial, they often do not cover all medications and those patients with incomes above the cut-off are still paying hefty sums. Not to mention, patients without insurance are left to pay directly out of pocket. Before large scale reforms and national price control measures begin to be entertained in public debate, patients and physicians must do all they can to find other ways to help defray some of the cost. With this The Importance of Efficient Office Practice in Meeting the Health Needs of the Community Project Date: 5/6/2002 Working with the neediest members of the community results in lower reimbursement for the physician meeting these needs. The lower reimbursement rates for patients on publicly-funded insurance have made it impossible for physicians in some communities to continue caring for these patients. For physicians who continue to see patients with public insurance, the expense of caring for these patients must be kept to a minimum. By creating efficient processes for billing and other functions in the office, expenses can be kept to a minimum, which helps enable a practice to continue to care for the most vulnerable patients. This project focused on creating an efficient billing process that gathers all of the necessary information for making successful claims to insurers for services rendered. Additionally, time was spent training staff on using billing software to streamline the process and maximize efficiency. Financial Implications of Early Death to South Coast Hospice Project Date: 3/25/2002 At South Coast Hospice, reimbursements from Medicare and private insurance are insufficient to meet patient expenses by approximately 300,000 dollars a year. As a result, South Coast Hospice(SCH), like many other hospices relies heavily on grants and fundraising to meet expenses beyond reimbursement. For this project, data from SCH was used to calculate death trends and their financial impact on SCH. This information was then presented to area physicians along with studies suggesting ways to make hospice financially independent of grants and donations. The results of the data showed that 31 percent of all patients admitted to SCH die within seven days. Eight percent of patients desiring hospice die before admission. The median length of survival from the time of admission is 17 days. Meanwhile, patients who die within seven days cost 3 times as much to care for when compared with those living beyond 17 days. As a result, Medicare's reimbursement plan of $116.40 per patient per day makes patients who die early unaffordable. State data shows that for hospice to break even, patients must be enrolled in hospice for at least 33 days. Besides presenting the financial data of hospice to physicians, multiple prognostication studies were reviewed which suggest that poor prognostication contributes to the financial deficit of SCH. Physicians overestimate time to death by a factor of 3-5. In addition, prognostic information is frequently withheld, leading to unrealistic patient expectations and delayed hospice admission. Experts suggest that open communication and early discussion of hospice with patients, even with those who have a good prognosis, can improve patient satisfaction, facilitate earlier hospice admissions, and reduce the reliance of hospice on grants and donations. Effects Of The Oregon Health Plan In John Day, Oregon. Project Date: 9/24/2001 Since the Oregon Health Plan was implemented in 1990, there has been a statewide decrease in per capita health care costs, a greater than 50% reduction in uninsured children, and a nearly 50% reduction for adults. (1) OHP has clearly made a positive impact on the shape of health care in Oregon. I became curious about the impact of OHP on rural clinics and communities while rotating at Strawberry Wilderness Family Clinic in John Day, Oregon. Does accepting OHP patients put rural physicians and clinics at a financial disadvantage? Has OHP accomplished its goal of ensuring adequate health coverage to the people in rural communities? SWFC has three family physicians and one PA who, along with two other family doctors, provide the entire population of Grant County with primary care. These five physicians see outpatients, manage inpatients, and cover the Emergency department. They are extraordinarily dedicated and possess diverse skills. The sources of my information were varied, including discussions with professionals in various realms of the health care industry, statistics and reports published by the Oregon Health Policy and Research office and AHEC, financial data provided by the clinic administrator, and legislative reports. What follows is a synopsis of the information I gathered. This information leads me to believe that even under a fully capitated managed care environment, the clinic is quite successful and the community is well served by the Oregon Health Plan. The Rising Cost of Medications. What's a physician to do? Project Date: 2/11/2002 This preliminary survey sought to establish whether insurance coverage excluded financial strain due to medication costs among patients at the Cascade Medical Clinics in Redmond, Oregon. The design is a cross-sectional study involving patients 18 years and older who were seen in clinic between March 7,8, and 11th, 2002. A survey which included name, DOB, insurance, type of drug coverage, and whether or not medication costs have ever caused the patient financial strain was distributed to patients in the lobby and returned at the fron desk. During the three-day period, 100 surveys were returned. Fourteen surveys were excluded based on age (less than 18 years old), or missing answers. Of the 76 valid surveys, 66% of patients reported having some form of pharmaceutical coverage. Of the 66%, 42% reported having significant financial strain due to medication costs despite insurance. This report discusses the rising concern of pharmaceutical costs, and what every physician should be doing to help control these costs. Surgery in Reedsport, OR: Its Impact On Lower Umpqua Hospital. Project Date: 8/13/2001 Most hospitals rely on their surgical facilities for financial stability. The capability to support full-time surgical staff becomes particularly important to the survival of rural hospitals, which often reside in low-populated and economically limited areas. Lower Umpqua Hospital (LUH), located along the Southern Oregon Coast in Reedsport, is an example of a rural hospital that has experienced financial hardship. After many substantial efforts and changes, including the hiring in 1995 of one general surgeon based in Reedsport and five surgeons who share their surgery time between Reedsport and other nearby towns, LUH currently enjoys financial recovery. This project seeks to understand how the recruitment of Dr. Toshio Nagamoto, the first and only surgeon living and working full-time in Reedsport, has affected the financial security of the Lower Umpqua Hospital (LUH). A timeline was first developed to illustrate the surgical services available to LUH over the years. The first surgeon to significantly increase the surgical services offered at LUH was an orthopedic surgeon hired in 1994, who shared operating time between Coos Bay and Reedsport.The general surgeon, the first and only surgeon to be based in Reedsport, was hired in 1995, and LUH has since brought on five additional surgeons, all sharing operating time between LUH and other hospitals along the Southern Coast. Hospital financial statistics reveal that Dr. Nagamoto's general surgery practice generates the majority of the total hospital revenue earned from all surgery at LUH. Gross revenue at LUH has increased by 110%, as compared to increasing by 67% in the five years preceding him. Additionally, LUH has increased total staffing by 64%, including a 30% increase in the surgical nursing staff, since 1995. The average daily census at LUH as risen from an all-time low of less than 2/day at one point in 1991, to a yearly average approaching 8/day this year. Remarkably, total surgery visits have increased by 2.7 times since the averages seen from 1992-1994. The average inpatient days of service and average intensive care unit patient days have increased since 1995 as well. Hospital financial data indicate the positive impact of a resident surgeon on the financial security of LUH. This data indicates the benefit and ultimate necessity of gaining a full-time local surgeon for LUH and for the community of Reedsport, Oregon. The Economic Burden of Cigarette Smoking at the West Salem Clinic and the Effects of Cigarette Prices on Tobacco Use. Project Date: 8/13/2001 The burden of cigarette smoking is not only manifested in disease but also in economic expense. This economic expense can be direct as in the amount spent to maintain one's smoking habit. As well the expense can be indirect as in the amount spent to ameliorate the untoward effects of the smoking habit. This study attempts to determine the economic burden of cigarette smoking in patients seen at the West Salem Clinic as well as determine the efficacy of increasing the costs of cigarettes as a means to curb smoking in this population. Measure 12-35: A Community In Conflict Project Date: 7/2/2001 Change is never easy. Some face it with optimistic curiosity; others cling to the old with a titanic grasp. To regard things new with some apprehension is human nature. We are constantly comforted by the familiar, and often resist the unknown. In the United States, however, and especially here in Oregon, we pride ourselves in our ability to initiate and adapt to changes in our society. Oregon was the first state in the union to adopt legislation to protect its natural habitat (State Sanitary Authority, 1938). It was also the first to expand Medicaid healthcare coverage for its poorest citizens (Oregon Health Plan, 1989), and the first to give its terminally ill the right to die (Death with Dignity Act, 1994). Yet sometimes our ability to resist change can with such intensity rival our ability to accept it. With every move there is a counter, with every decision, controversy. In September of 2000 a special election was held in Grant County, Oregon to provide funding for the remodeling and renovation of Blue Mountain Hospital in John Day, Measure 12-35, which authorized general obligation bonds of up to $7,000,000 for hospital construction, narrowly passed carrying only 50.9% of the popular vote. From the moment of its inception to well after the measure had passed, the issue was entrenched in controversy. Those offering support were committed to providing adequate healthcare services to the surrounding community, while those opposed stressed social and economic concerns. Both sides were adamant in their beliefs, and the ensuing conflict proved turbulent for the small communities of eastern Oregon. Back to subject search page or search by preceptor site