RCHC Community Project Abstracts

Back to subject search page or search by preceptor site Integrating Education on Postpartum Issues into Existing Birthing Classes for Pregnant Women Project Date: 10/12/2009 Although the prevalence of postpartum depression (PPD) amongst mothers on the Warm Springs Reservation is unknown, many of the risk factors for PPD are epidemic issues amongst this population. Risk factors include previous depression and social factors such as little support available from family or friends, difficult or stressful marriage or relationship, and stressful events occurring during pregnancy or after childbirth. Unfortunately, many of the prenatal patients seen at Warm Springs Wellness clinic have social stresses such as an unplanned pregnancy while they are young and single, past or current domestic violence, issues with alcohol abuse or family members and partners who abuse alcohol. These stressful and unstable social factors can become risk factors for the development of PPD. The Warm Springs Wellness clinic has many effective no-cost programs for parents including educational birthing classes, WIC, lactation consulting, home nurse visits after birth, free child car seats and parenting classes to help address many of the issues that affect mothers and their babies. Discussion and education around postpartum issues including PPD was one aspect that was missing from the great programs already established. As part of my project, I developed a presentation for expecting parents regarding postpartum issues and presented these topics to parents at prenatal clinic and birthing classes. I also created an educational pamphlet about the baby blues and postpartum depression for the Warm Springs Wellness Clinic to be displayed in patient rooms and provide more information on the issues and warning signs. Analysis of mental health disorders at Dunes Family Health Care, in Reedsport, OR. Project Date: 10/12/2009 Background: Studies show that primary care physicians in rural communities have to play a larger role in mental health care when compared to urban physicians. This is due to the fact that in many rural communities primary care clinics are the only accessible mental health resource for much of the population. There are many that believe that primary care physicians lack the training, skills, and time necessary to shoulder this larger burden. Introduction: The goal of this project was to determine at what frequencies mental illnesses are seen in clinic at Dunes Family Health Care in Reedsport, OR; what the demographics of these patients are; and what treatments are commonly implemented. It was hoped that this data would be valuable to Dunes Family Health Care clinicians as it could be used to better help allocate the clinics’ mental health resources in the future. Methods: Using the clinic’s electronic database, lists of patients with the most common mental illnesses were attained using the corresponding ICD9 codes. Records were pulled from the 2008 calendar year. Random charts were selected from the lists and reviewed on the basis of age at the time of visit in 2008, gender, number of visits for this problem in 2008, new problem in 2008 or follow up, and common treatments. Results: A total of 191 individual patients were identified using the diagnostic codes which accounted for an estimated 15.5% of the total patients seen in 2008. Depression was the most common diagnostic category with 38.8% of the diagnoses. Close behind was Anxiety with 31%. Next was ADHD with 16%, followed by Bipolar disorder and Dementia both with about 6%. PTSD had 2.5%. Schizophrenic disorders yielded 0%. Discussion: Much of the data correlates well with prior studies, specifically with regard to depression and anxiety data, including type and frequencies of medication regimens. Unfortunately, this study had significant limitations. The sample size was not very large for many of the categories which significantly reduces our ability to trust that the data is representative of the population in question. This was likely due, in part, to the fact that ICD9 codes were many times not recorded for a variety of reasons. Also, ICD9 codes may not be the best tool for this type of analysis because patients are often given the wrong code. Late-Life Depression and Psychosocial Factors: Clinical Screening Tools and Social Services for Older Adults in Junction City, Oregon. Project Date: 10/12/2009 Depression in common among older adults in the United States. Contributing factors to depression include biological, psychosocial, and environmental elements. Bereavement, caregiver strain, social isolation, financial strain, and physical disability are among the many psychosocial factors that contribute to the development of depression. Depression among older patients is important not only because it compromises quality of life for patients and their families and undermines the ability to maintain health and independent living, but also because it is an independent risk factor for mortality. While the development of pharmacologic agents for the treatment of depression have made significant impact on quality of life for many individuals, the continued importance of screening for and addressing psychosocial issues cannot be overstated. The goal of this project was to screen older patients in the Junction City area for depression, explore the psychosocial context in which depression exists, and educate health care professionals on the community resources available to address issues such as financial strain and social isolation. The Patient Health Questionnaire 2 was used to screen for depression and a student-designed questionnaire was used to screen for social isolation, community involvement, and daily activities. These two questionnaires, combined with brief patient interviews, revealed some correlation between depression and social isolation. To address issues of late-life depression and the underutilization of social services in the Junction City area, a notebook was developed for use by health care professionals at the Junction City Medical Clinic that included 1) a series of clinical tools for screening for depression, dementia, and activities of daily living; 2) a series of journal articles on the role of psychosocial factors in depression; 3) a questionnaire for use in screening for social isolation and obstacles related to community involvement; 4) information related to enrollment in Medicare through the Senior Health Insurance Benefits Assistance program, the Oregon Prescription Drug Program, and social services available through the Senior & Disabled Services office in Junction City; and 5) an article on house calls. Screening for Dementia in the Primary Care Setting: Experiences at the North Bend Medical Center, Coos Bay, OR Project Date: 6/29/2009 Background: Dementia has emerged as a large and growing health care problem but it is often not diagnosed until later in the disease progression. Early diagnosis has the potential to minimize the burden on patients, family and caregivers; however, no randomized trial has evaluated the efficacy of dementia screening in primary care. Introduction: The purpose of this project was to determine whether a brief screening for dementia in this particular type of primary care setting would identify patients with some memory or cognitive impairment that required further neurocognitive testing. Another purpose of this project was to identify barriers to screening for dementia in this setting. Methods: In order to accomplish these goals, all patients over 70 years old without particular memory concerns were screened for dementia during a two-week period at one Internal Medicine Clinic at North Bend Medical Center in Coos Bay, OR. Also, a survey of Family and Internal Medicine physicians at NBMC was conducted to identify their perceptions of undiagnosed dementia in the community and to determine what prevents them from routinely screening their patients. Results: 20% of the patients screened had an abnormal Mini-Cog screening and 30% had an abnormal MMSE screening. 83% of physicians felt that many of their patients might have undiagnosed dementia. 80% cited a lack of time as the principal factor preventing them from screening. Only 20% frequently used the Mini-Cog for screening. Discussion: The fact that these patients were discovered is information that can be used to explore the issue of whether or not screening asymptomatic elderly individuals in this setting would actually be beneficial in detecting previously undiagnosed dementia. Some of the barriers that physicians identified to screening could potentially be resolved. 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. Stress Induced Illness; diagnosis and treatment in Lebanon, Oregon Project Date: 3/16/2009 The primary goals of this project were to better understand the diagnostic approach to stress-induced illness and effective treatment modalities. These questions arose from patient interactions surrounding stress-induced illnesses which left both the patient and provider feeling frustrated and confused. I recognized my own inability to effectively diagnose and treat stress-induced illnesses and wanted to know more. On further examination, I found 27% of patient visits to the PCP office in Lebanon, OR, over a 5 week period, were related to stress-induced illnesses. These included chronic back, neck, and body pains without clear etiology, depression, anxiety, irritable bowel syndrome, and generalized fatigue. Patients often re-presented with repetitive pain complaints after steroid injections, medications, or “tincture of time” did not adequately treat their illness. Methods: I interviewed specific inpatients and outpatients, selected based on their diagnosis of exclusion, stress-induced illness. I investigated the pathophysiology of stress-induced illnesses, diagnostic algorithms, and treatment modalities through literature review. Finally, I followed up with as many patients as I personally saw in clinic, to better understand the efficacy of different treatments. Results: Stress-induced illnesses are prevalent in the primary care setting, making up 27% of Physician-visits in Lebanon, OR over a five week period. Effective treatment is time consuming up front, but inexpensive. When appropriate treatment is implemented, it has the potential to save over five hundred dollars and ten physician hours per week, not to mention, considerable human suffering. Available resources for patients with mental health concerns Project Date: 3/16/2009 Mental health issues, depression and anxiety in particular, are a concern common to urban and rural populations alike. Due to the generalized scarcity of resources often found in rural and frontier settings, access to care is a major concern given difficulties with both maintaining appropriate mental health services as well as the limited ability for patients to afford them given high rates of poverty and lack of insurance. By interviewing medical and mental health providers in Coos Bay and North Bend, this project seeks to identify available resources for patients with mental health concerns and qualitatively assess how well these are being utilized by the healthcare community. Helping Chronic Pain Patients Improve their Pain and Functioning Project Date: 3/16/2009 Chronic pain is frustrating for patients and physicians alike. It is costly to society in terms of lost productivity and high use of health care resources. Medications are one component of managing pain, but they are most effective when combined with exercise, relaxation, nutrition, and counseling. Like patients with other chronic diseases, those with chronic pain must move from being passive recipients of care to informed, active participants if they are to improve their functioning and quality of life. This project consisted of designing a group visit with an educational didactic session followed by brief individual visits using measurement tools and a standardized progress note to set and evaluate goals, progress, and effectiveness of treatment plans for OHP patients in Silverton, OR. While this project is an attempt to implement a chronic care model with limited resources of a small practice, patients could certainly benefit from a counselor specializing in cognitive behavioral therapy. 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. Acute Psychiatric Care for the Underserved Population of Ontario, OR Project Date: 2/9/2009 There is an increasing demand for psychiatric care and a decreasing supply of corresponding resources in rural Oregon, including communities like Ontario and greater Malheur County. Although availability and access to psychiatric care is a problem throughout the United States, significant obstacles exist in rural areas that create unique issues that are not easily overcome. Specifically, while primary care physicians serve to treat common mental health conditions such as anxiety and depression as part of their daily practices, specialty care needed to treat more complicated mental health cases and acute psychiatric crises are becoming increasingly scarce. In the case of the emergency room, hospital staff must overcome a number of hurdles when assessing, evaluating and referring every single psychiatric patient. This is especially evident at the Holy Rosary Medical Center (HRMC) hospital in Ontario, Oregon, where numerous factors combine to make treatment for the acutely mentally ill frustrating at best and impossible at worst. The goal of this project was to: 1) formally investigate these problems and complications; 2) discuss the barriers as they exist in their current state; and 3) suggest some reasonable recommendations that could be implemented to improve present conditions. Depression in Warm Springs Project Date: 10/13/2008 Depression is a serious condition that affects the mind and body, associated with a host of co-morbidities and potentially resulting in suicide. Factors associated with increased prevalence of depression that are certainly found in Native American communities include poverty, displacement, and relative lack of jobs. However, there are some barriers that prevent the people of the Warm Springs reservation from getting counseling help for depression, such as cultural factors, lack of knowledge about the local Counseling Center and its services, and misconceptions of poor patient confidentiality and costly services. To address the issue of depression in the Warm Springs community, I designed a pamphlet for the Counseling Center that would help in getting the word out to the community about the Counseling Center and the services they offer, appeal cross-culturally, aid in screening for depression, provide resources to help intervene, and dispel misconceptions. Assessment of the Mental Health Resources in Milton-Freewater, OR Project Date: 10/13/2008 There is a universal need for mental health services in all areas of rural Oregon, including communities like Milton-Freewater. Additionally, there is an appreciable discrepancy between the services that are available for those who have private insurance, those who use state or federal plans such as OHP and Medicare/ Medicaid and those who have no health coverage. While this may be true for both urban and rural communities alike, there are other additional obstacles more unique to a rural area. Also, some of the mental health care can be provided by local primary care practitioners, however, they often lack the time and the specialized knowledge necessary for anything but maintaining patients that are already stable and in good control of their disease. Additionally, in a rural setting where social workers are not readily accessible, making it more difficult for physicians to know the local resources available in order to effectively help their patients. It was a general consensus from those interviewed for this project that the mental health resources of Milton-Freewater are lacking in many ways; however, there are still some very important services to be used. The goal of this project is to show both what resources are and are not available with the hope that those resources that still exist will be more effectively used. Reviewing the Changeways Program as a treatment for depression in a rural setting Project Date: 6/30/2008 Mental health care treatment options are limited in the Coquille area. The Changeways Depression Program is a psychoeducational group therapy protocol designed to introduce clients to basic psychological self-care concepts. A group of patients with depression went through the 10-week program earlier this year. In this rural project, interviews were used to review the effectiveness of the program from the group members' perspectives. Overall, the group support setting was appreciated by the participants, and the lesson material was well liked, even though all of the group members still suffer from depression and all continue to take antidepressants. It is the conclusion of this project that the Changeways program should continue to be used, with increased recruitment effort and better data collection. Screening for Depression in the Elderly in the Primary Care Setting: Piloting the Use of a Two-Item Questionnaire in Florence, OR Project Date: 4/28/2008 Depression is a major health issue among the elderly, with approximately 10% of adults aged 65 or older suffering from clinically significant depression. This problem is particularly relevant to Florence, OR, which has a large and growing retirement community. A major obstacle to addressing this issue in the primary care setting is that of efficiently screening for depression in a geriatric population with many co-morbidities that can confuse or overshadow mental health issues, and limited time to administer screening tests. Currently, elderly patients at the Florence family practice are only screened for depression at certain visits, such as annual diabetic exams. This project piloted the use of the two-item Patient Health Questionnaire 2 (PHQ-2) among all elderly patients visiting their family practice doctor in Florence, OR as a brief, efficient means of identifying depression in this population. The screening questions were verbally asked of patients age 65 or older, and the questionnaire results were analyzed to determine both total rate of positive screens and the number of these that were previously undiagnosed as depressed. The results of this pilot use indicate that incorporating the PHQ-2 into regular screening of elderly patients visiting the clinic could substantially improve detection of depression in this demographic. Mental Health Care Practitioners in Philomath, OR: Difficulties with access and availability. Project Date: 4/28/2008 The supply of both prescribing mental health care providers as well as licensed therapists in rural settings in the United States is a major problem. Subsequently, there is a significant shortage of available providers to see patients in a timely manner. Although many primary care physicians, such as family medicine doctors, are capable of supporting and treating many patients with psychiatric problems, most lack both the time necessary to engage in meaningful therapy as well as the skill set required to manage acute mentally ill patients well. For these reasons this project was developed in order to better characterize the local deficiencies in mental health care services and access as well as to offer a potential solution by generating a viable list of providers in the area that are accepting new patients. A general consensus within the Philomath Family Medicine clinic indicated a shortage of rapid access to prescribing mental health care providers was present and that more providers were needed in the area. A provider list was generated four years earlier through a similar project, although many of the physicians, counselors, and therapists on that list were either no longer in the area, or they were no longer accepting new patients. The primary care physicians felt an updated list of social support structures (public and private), psychiatrists, counselors, and therapists in the area would be of value. Through the use of various resources, a thorough list was created and included such information as a description of the practice with areas of interest/specialization unique to the provider, the current waiting time to be seen, eligibility requirements, and payment structure. Barriers and Solutions to Receiving Adequate and Continuous Mental Health Services Among the Underserved Population in Lane County Project Date: 3/17/2008 Mental illnesses have a long history of being grossly underdiagnosed and undertreated. This is especially true for the medically underserved because they are not able to receive the health care needed to treat their mental illness. This problem stems from several major factors which were investigated during this five week clerkship. There were two main goals to this project. The first was to take a closer look at the barriers contributing to this problem, especially from the perspective of the provider. The design was to interview people in the community who treated members of the medically underserved and had a good understanding their social/mental problems. The second goal of this study was to identify what resources were available and what measures were being taken by the community to address this problem. Despite high levels of awareness in the community regarding the great need of mental health services for the indigent population, there exists many barriers preventing the progress of accessibility, availability, continuity of care, and general knowledge of services. Included is a handout summarizing mental health services in Lane County produced by the 100% Access Healthcare Initiative, a group geared towards providing services to all members of Lane County. Access to Mental Health Resources in the Astoria Area, A Narrative Survey. Project Date: 3/17/2008 Mental health complaints are extraordinarily common in the primary care setting with a prevalence of up to 50%. Primary care physicians do the bulk of routine mental health care in all settings but this is particularly true in rural areas. What resources are available to them when they have patients requiring more specialized care? A qualitative survey of mental health care resources in the Astoria was done. Many of the obstacles to care were found to be similar to those of an urban environment: poor access for the uninsured, providers unwilling to accept Medicare patients. Other obstacles were more unique to a rural area, specifically the lack of local inpatient psychiatric beds and certain other specialized psychiatric services such as methadone maintenance clinics or inpatient treatment for eating disorders. Overall PCPs in Astoria have ready access to such referral services as counseling and therapy as well as to psychiatric prescribers. Overall all of the health care providers surveyed seemed to enjoy the benefits of living and working in a small town. Intimate Partner Violence: Toward an Inclusive Paradigm Project Date: 2/11/2008 Background: Intimate partner violence (IPV) is an important public health concern, associated with many significant adverse psychological and physical health consequences. The Centers for Disease Control and Prevention estimates an annual national cost of IPV of $5.8 billion, with $4.1 billion attributable to direct medical and mental health services costs. A large body of evidence shows that a substantial percentage of victims of IPV are males. Despite widespread recognition of the impact of IPV on public health, and despite concentrated efforts for better prevalence data collection processes by the CDC and others, the role of male victims in prevention and treatment strategies is frequently underestimated and marginalized. To facilitate better understanding of male victimization and informed intervention strategies within the community, we sought to elucidate the services available for male victims of IPV in Eugene, Oregon. Methods: We performed a literature search on national, state and local prevalence rates of male victims of intimate partner violence. Data on community resources for IPV were gathered using the Internet, the community phonebook, and resource listings provided by the City of Eugene. We conducted interviews with staff members of community organizations providing services for IPV to ascertain service availability by patron sex. Results: We found that the majority of community IPV services were available to men and women with relatively few instances of sex-specific eligibility for services. Significant discrepancy existed between advertised sex-specific eligibility for services and actual sex-specific eligibility for services. Conclusions: Of the available resources in Eugene, Oregon dedicated to providing services to victims of IPV, nearly all of them are available to men as well as women. Nonetheless, several barriers to care were identified that may hinder access by men to these resources. These include IPV data collection processes that exclude men from survey pools, intervention strategies that seek to identify only female victims in the health care setting, and language and terminology in educational materials that phrases IPV as a gender-specific form of violence. Improving information and support services available for parents of autistic children Project Date: 9/10/2007 The prevalence of autism in the United States has increased over the last ten years. Parents of an autistic child face many challenges, as their child often has additional health care needs such as physical, occupational, and speech therapy, and requires specialized educational programs. Parental support and education about autism are important aspects of caring for an autistic child, as a child’s home environment can greatly improve his/her overall functioning. The goal of this study was to evaluate what kind of information and resources parents of autistic children at Siskiyou Pediatrics in Grants Pass, Oregon were given. Interviews with pediatricians and parents revealed the need for a concise patient brochure with information on local and regional autistic services. Through an internet search, different agencies providing parental workshops and support groups in the southern Oregon region were located. As a result, a patient brochure was created which the pediatricians at Siskiyou Pediatrics can give to parents of autistic children. Hopefully, this information will be beneficial to parents as they will be equipped with the tools they need to understand, manage, and improve their child’s condition Communication Between Mental Health and Primary Care in Grants Pass: Screening Templates for Patients on Psychiatric Medications for Healthcare Continuum Project Date: 7/2/2007 Access to healthcare, especially mental health, is more difficult in rural settings, with many more patients continuing their mental health treatment in the care of their primary physician than patients in urban areas would. Beyond the poor access of mental health services, communication between mental health and primary care has been identified as a problem for many years. This lack of communication between mental health and primary care is a significant obstacle to continued patient care. The medical directors of both the Independent Physicians Association and Options for Oregon mental health services were interviewed for their assessment of overall status of, barriers to, and current methods of improving this communication. This project addressed the specific need for primary care monitoring of patients being treated with specific psychiatric medicines. One template was created for second-generation antipsychotics, a high-risk class of drugs that significantly increases these patients’ risks of morbidity and mortality from heart disease and diabetes which include Clozaril, Zyprexa, Seroquel, and Risperdal. Another screening template was created for the drugs Lithium, Depakote, and Trileptal. These two templates were created to provide primary care physicians with pertinent screening information necessary to maintain the health of patients taking these psychiatric medications. Traumatic Brain Injury in Harney County Etiologies and Incidence of Emergency Department Visits, Hospitalizations and Deaths Project Date: 7/2/2007 With a population of 7,660 people spread over 26,486km2, Harney County is the most sparsely populated county in the contiguous US and has a low enough population density to qualify it as a “frontier territory”. Given the abundance of uninhabited land, ranching, hunting, off-roading and other outdoor activities are an integral part of the Harney County culture. These pursuits however provide additional potential risk factors for head injuries and thus might predispose the population of Harney County to increased rates of traumatic brain injuries. The purpose of this study is to assess the impact of Harney County’s frontier-county lifestyles on the rates, etiologies, and outcomes of traumatic brain injuries in Harney County. An examination of national, state, and county data on TBI incidence, etiology, and outcome was performed for comparison. National and state data were obtained from online databases while Harney County information was obtained from Harney District Hospital records department. Analysis of primary data found that there is an increase in the incidence and overall proportion of traumatic brain injury from direct livestock-induced injury, secondary injury from MVA-livestock collisions, and off-road related ATV rollovers compared to other etiologies except falls. The overall incidence of TBI’s in Harney County was found to be slightly higher than that of the national or state incidence rate By identifying common causes of head trauma in Harney County, local providers can identify higher risk communities and at-risk individuals and can thus emphasize patient-specific strategies for prevention of future head trauma. Antenatal Depression in Klamath Falls, OR; development of a patient handout for use in patient education for at risk women Project Date: 3/19/2007 Depression during pregnancy and in the postpartum period is a major public health concern in the United States affecting approximately 20% of all pregnant women. This study attempted to assess the process of identifying women at risk and educating them on available options in the Klamath Falls Family Practice Residency Clinic. The design was observation of family physician's, obstetrician's, and psychiatrist's interaction with pregnant patients and patients with mental health problems during a five week rotation in a high-risk area. One faculty psychiatrist is the primary referral source for patients with medication questions. For counseling services patients are referred to Klamath County Mental Health. Patient openness to discuss the topic of depression and mental health concerns in general was observed. While the topic of depression was addressed when a patient initiated the discussion there appeared to be no standard method for screening pregnant patients for depression or discussing treatment options in the event of depression occurring. Also, although there were information handouts regarding depression, there was nothing specifically targeting pregnant or postpartum women. Thus the main goal and final product of this project was development of a patient handout for pregnant patients and those considering pregnancy with concern about depression and anti-depressant treatment. Screening for Depression Project Date: 3/19/2007 Depression is the most common psychiatric disorder making it a very important issue in primary care practices. This project looked at ways to screen for depression in rural primary care offices, the effectiveness of doing so, and what to do with positive screening results. Design began with observation of an internist’s interaction with patients throughout a five week rotation. Literature review and professional contacts were utilized to evaluate the evidence regarding the efficacy of depression screening in primary care and what tools are most useful if it is to be done. The result of this project was the incorporation of two screening questions into the routine ‘rooming procedure,’ with a follow-up questionnaire for positive screens, informing the staff about what to do with a positive screen, and making information about non-pharmacologic community resources readily available. The Role of the Primary Care Provider in Identifying And Treating Postpartum Depression Project Date: 2/12/2007 Postpartum depression (PPD) is a significant public health problem in the US affecting approximately 1 out of 8 women. Antenatal depression can also occur and when present, is a risk factor for PPD. Although the prevention and treatment of PPD (or perinatal depression) is a public health priority, screening for the disorder is not typically standard of care and therefore PPD is often under diagnosed and inadequately treated placing women, infants and families at risk. Because multidisciplinary primary care providers usually have the most mother/child contact, they are in a prime position to screen for depression and identify risk factors that might lead to PPD. Risk factors such as poor partner/family relationships, lower socioeconomic status, unemployment of self/partner and lack of social support are not uncommon in Eugene, Oregon. The purpose of this project was to: 1. Increase the awareness among the PeaceHealth system (PHS) primary care physicians and midwives of the importance of identifying, treating and/or referring cases of PPD. 2. Introduce a validated screening tool for identifying women at risk of developing or suffering from PPD. 3. Provide a referral list for the treatment and support of PPD. 4. Invite clinician participation in the Lane County PPD Consortium, 5. Provide a PPD screening tool for the PeaceHealth Sacred Heart Hospital labor and delivery social workers. Methods: The patient statistics justifying this project came from 2006 and reflect the number of all PHS physicians’ patients who gave birth at the PHSHH. Information was gathered through conversations with PHS physicians, ancillary staff, the Lane County PPD Consortium and several others. An informational packet (IP) was prepared and distributed to individuals involved with the identification, treatment, referral and quality care of patients with PPD. Findings/Results: Last year, the percentage of diagnosed cases of PPD among PHS primary care physicians’ patients who gave birth at PHSHH was .18%. This is far short of the estimated prevalence of 10-20%. Screening for PPD is not standard of care for primary care doctors in the PHS. Many doctors reported they did not have time to use the IP screening tool and there was a general lack of knowledge of the importance of the role of the primary care provider in addressing the problem of PPD. There were no reported cases of PPD diagnosed during the five week clerkship. Borderline Personality Disorder and Dialectical Behavioral Therapy in Coos Bay, OR Project Date: 2/12/2007 Borderline personality disorder (BPD) is a DSM-IV Axis II disorder seen in approximately 2% of the population, with higher prevalence in primary care settings. Primary care providers (PCPs) are often challenged by patients with BPD, and in many cases do not recognize these patients who often have higher levels of health care utilization. A treatment for BPD that has proven effectiveness is dialectical behavioral therapy (DBT), a structured psychotherapeutic intervention, which is available in Coos Bay, Oregon as a college course. This project sought to improve health care for patients with BPD in the Bay Clinic of Coos Bay, who face significant limitations in available mental health providers in the area, and thus rely on PCPs for mental health treatment. Ten PCPs were interviewed regarding their knowledge about BPD and DBT, revealing limited knowledge of both of these subjects. Interviews of patients with BPD revealed a lack of communication about their diagnosis and treatment with their PCPs. Informative material about BPD and DBT was provided to PCPs at the clinic. A guide with yes-or-no questions was established and distributed in order to assist PCPs in evaluating patients for potential referral to DBT, and PCPs were provided with materials for patients about the course. Limitations included the use of handouts and lack of time and resources to evaluate outcomes. Depression in the Elderly - Community Resources in Reedsport, Oregon Project Date: 2/12/2007 Depression is a common problem in the elderly population. Literature shows that exercise and social interaction have a tendency to improve and maintain good mood. The goals of this project are to first explore the resources in the community for the senior population, then to evaluate the utilization of these services by conducting a survey, and lastly to develop a patient handout to increase awareness of local resources and to encourage physicians to incorporate exercise and social interaction into treatment plans for elderly with dysthymic mood. Many activities and programs through the senior centers and the senior & disability services are available locally. However, only 50% of those with dysthymic mood use the senior center, while 78% of those with good mood utilize the services. In addition, those with lower mood score are less likely to have a regular exercise schedule. In a rural setting where social workers are not readily accessible, it is beneficial for physicians to know the local resources in order to effectively help their patients. Meet Me In The Woodshed A Tragedy in a Small Town: Recognizing and Preventing Suicide in the Elderly Project Date: 1/1/2007 Elder suicide is major issue in Oregon and the United States. Suicide rates among persons age 65 years and older are the highest compared to any other age groups. In 2003 in Oregon, the suicide rate per 100,000 in people aged 65 years or more was more than twice the rate in people aged 15 to 34 years old (27.14 versus 13.41). This project aimed to quantify the problem of elder suicide, identify risk factors both generally and specific to Oregon and Tillamook County, and propose prevention strategies for the community and physician. Data sources included research studies on elder suicide, census and CDC statistics, and interviews with community professionals involved with suicide prevention and treatment. Risk factors for elder suicide overall include chronic disease, social isolation, and the misconception that elder depression is a normal part of aging. Oregon has the 4th highest elder suicide rate in the county and some factors specific for the elder Oregon population include living in a rural setting, “rugged individualism”, and firearm ownership. Physicians can help prevent elder suicide by encouraging a warm and trusting relationship with patients so that they feel safe sharing depressive thoughts. Physicians have tremendous power of influence with their patients’ health care decisions and can strongly recommend counseling and treatment for patients at risk. In the upcoming year, the Oregon DHS plans several community meetings to develop prevention strategies specific to the local area. Finally, a refrigerator magnet with important contact numbers for outreach and counseling services was designed for elder patients to have at available at home. The hope is that in the future, elder patients considering suicide will contact his friend, doctor, or counselor to begin their path to recovery. Assessment of Resources Available for Persons with Dementia in Florence Project Date: 1/1/2007 The population of persons over 65 is rapidly growing in the United States and this is especially true in rural communities, such as Florence, where this population makes up close to 40% of the total population4. One family practice clinic in Florence had close to 45% of its patients over the age of 655. Naturally, this would increase the number of age-related diseases, such as dementia, seen in this clinic compared to an average practice. Therefore, it is important for physicians to have easily accessible resources for themselves as well as for their patients. A resource guide was produced to help health care providers in the clinic better serve their patients with dementia. Managing Medical Complications of Eating Disorders in the Outpatient Setting Project Date: 10/16/2006 "Eating disorder patients can be challenging for physicians to manage since there are many medical complications that arise in the setting of starvation or persistent purging. These medical complications put patients at risk and can add considerable cost to the health care system if not addressed properly. The purpose of this project was two-fold: 1) to identify the most important medical problems experienced by eating disorder patients that should be looked for and treated, and 2) to develop a screening tool for physicians to follow the symptoms of medical complications and guide treatment decisions. Visiting residents of an outpatient residential eating disorders treatment program outside of Eugene provided a unique opportunity to have good continuity with eating disorder patients and deal specifically with the medical (as opposed to psychiatric) aspects of their care. The population studied was a group of female patients diagnosed with either anorexia nervosa or bulimia nervosa that were currently undergoing medical, nutritional, and psychological intervention for their eating disorders. After reviewing the literature and conducting patient interviews, a worksheet of medical symptoms was created. The final product is designed to be filled-out by patients prior to seeing their doctor for medical appointments. The utility of such a tool is to focus the patient encounter towards relevant medical problems, to consolidate symptom information into one place, and to allow for the consistent tracking of the persistence or resolution of symptoms with treatment." Mental Health Resources in Grant County, Oregon: Current Status, Recent Changes and Accessibility to Patients Project Date: 10/16/2006 In 1973, the state of Oregon established a regional system of county community mental health programs to provide basic mental health services to all residents and alternatives to hospitalization for certain residents needing higher levels of mental health care. Since then, the movement of deinstitutionalization and the Oregon Health Plan, have contributed greatly to the number of people who seek care at county mental health programs across the state. Grant County’s community mental health program, the Center for Human Development (CHD), located in John Day, Oregon, is the only resource providing solely mental health services for the county’s 7,800 residents. Interview with CHD administrators identified the following challenges: lack of and difficulty retaining trained mental health professionals at CHD, ever decreasing funding and reimbursement for services, social stigma regarding mental health care, and difficulty perceived by CHD with interfacing with the existing family practice clinics in John Day. Additionally, the Strawberry Wilderness Community Clinic (SWCC) family practitioners have difficulty making successful referrals to CHD, getting progress reports from CHD on referred patients, and staying current in diagnosis and treatment of less common psychiatric conditions. Therefore: 1) an informational patient handout about CHD was prepared for distribution to SWCC patients, 2) conversations between CHD and SWCC were initiated to establish designated SWCC space and time for a CHD counselor to see referral patients, and 3) conversation was initiated to establish a designated family practitioner who could be contacted for medication prescription in the event of psychiatric crisis. The Development of a Systematic Approach to Mental Health Evaluations at Treasure Valley Pediatric Clinic in Ontario, OR Project Date: 9/11/2006 Treasure Valley Pediatric Clinic (TVPC) in Ontario, Oregon has a significant number of patients that are seen for mental health care with ADHD accounting for the majority of these cases. The clinic has a total patient population of approximately 5600 patients and 204 (3.6%) patients have a diagnosis of ADHD. Other common mental health issues seen at the clinic include depression (129 patients), anxiety (51 patients), and autism (25 patients). With a staff that includes one pediatrician, two physician’s assistants, two counselors, and a registered nurse that acts as a care coordinator, TVPC is well-equipped to meet the mental health needs of its patients, but it lacks a unified approach to the initial evaluation of these patients. The goal of this project was to learn more about how initial mental health evaluations are performed at the TVPC and to work with the various healthcare providers at the clinic to develop a unified approach to these evaluations. The final product of this project was the development of a protocol for initial evaluation of patients with possible ADHD and other mental health concerns. Mental Health Issues in Josephine County: Facilitating the Transition from the PCP's Office to Community Mental Health Services Project Date: 8/7/2006 Psychiatric illness is a major medical issue in the community at large and is too often under-treated. The problem of inadequate identification and treatment appears to be even more severe in rural areas. This study explores issues that render provision of mental health services in rural areas problematic and discusses a particular mental health issue, namely depression, in some detail. This issue is considered in the context of Josephine County with special emphasis on the Grants Pass area. A patient pamphlet was designed with the purpose of educating patients regarding the illness, screening patients for the illness, and informing patients of their options in the event that they did in fact feel depressed. Identifying a need for pediatric specialists in Coos Bay, Oregon Project Date: 8/7/2006 Coos Bay, Oregon is 212 from Portland, 111 miles from Eugene and 84 miles from Roseburg. These areas serve as the three major referral centers for pediatric specialists. Due to the excessive distance from specialist care, the need for greater compliance and increased quality of healthcare in rural areas the need for particular specialists in this area must be addressed. The goal of this project was to determine the current referral base for pediatric patients of the two major clinics in Coos Bay and to identify a need for a particular specialist in the area. The population studied included pediatric patients seen by the researcher while working at Bay Clinic and North Bend Medical Center during a four week period. The data gathered included type of specialist referral, problem or reason for referral, and location of the specialist. This data was correlated with qualitative data obtained from various pediatricians at both clinics regarding specialist needs, problems referred and where patients are referred. Qualitative data gathered indicates that there is a great need for a child psychiatrist in Coos Bay. Currently, there is one part-time general psychiatrist handling all of the Oregon Health Plan (Medicaid) patients. The barriers to efficient recruitment of physicians in rural areas needs to be further studied. Screening for Problem and Pathologic Gambling in Coos Bay, Oregon Project Date: 8/7/2006 Pathologic gambling and problem gambling affect as many as 5 to 15 million Americans. Primary care physicians are ideally situated to screen for maladaptive gambling behaviors and assist in patient referral and treatment. Using an adaptation of the NODS DSM-IV diagnostic screen for gambling problems, this project sought to determine the prevalence and impact of problem and pathologic gambling for patients seeking primary care at Bay Clinic in Coos Bay, Oregon where no such screening been done. Of fifty-two respondents, six (11.5%) individuals were identified as being probable problem or pathologic lifetime or past year gamblers; with 50% having a history of substance use disorder and 83.3% with a history of depression or mania. For the four respondents meeting criteria for problem and/or pathologic gambling in the past year, an average of 108 days and $2,266 dollars was spent for the year. Further study is needed, particularly to resolve concerns regarding the specificity of the adapted screening tool and possible reporter bias. Still, this initial work shows a high prevalence of probable problem or pathologic gamblers in the Coos Bay region and provides impetus for continued standardized screening. Management of Mental Health Emergencies in John Day, Oregon Project Date: 8/7/2006 Resources for appropriate treatment of mental health crises are limited in rural communities. The purpose of this project is to assess the infrastructure and clinical support for managing mental health crises in John Day, Oregon. This investigation included discussion with health professionals from the Blue Mountain Hospital and within the Grant County Department of Mental Health. These organizations provide care to the population of Grant County, as well as any patients presenting to the Blue Mountain Hospital Emergency Department. In addition to discussion with health care providers, literature searches were performed with the goal of assessing the strategies currently used by other rural communities for providing psychiatric care. In the course of this investigation, it was identified that the lack of a psychiatric hold unit within Grant County creates a particular challenge for managing patients in mental health crisis. Therefore, the discussion of this investigation will focus on this particular need and explore possible approaches to addressing the problem. Mental Health Resources in Linn County, OR for the Uninsured Project Date: 7/3/2006 Prevalence of uninsured patients in Oregon is on the rise. Among these patients are those with mental health needs. This project aims to assess the need for mental health care in Linn County and to research the available mental health resources for the indigent uninsured that are unable to pay for their care. Research was conducted through interviews with possible mental health providers. The organizations offering mental health care to the indigent were identified to include: Linn County Mental Health Clinics, Community Outreach Clinics together with Samaritan Health Care providers, Pastoral Counseling Center, and The Counseling Center of Albany. The ultimate goal was to develop a brochure to be made available for patients with mental disorders coming in to the Community Outreach Clinics in Albany and Lebanon, Oregon. A Chart Review of Domestic Violence and Specific Co-morbidities on the Warm Springs Reservation Project Date: 3/20/2006 There is a higher rate of domestic violence (DV) in Native American communities, and in turn certain medical problems (DMII, cholelithiasis and cholecystitis, ect) also occur disproportionately in native populations. While it is known that there are a number of co-morbid conditions and problems that victims of DV experience, this has not been examined at length in Native Americans. The clinic staff on the Warm Springs Reservation have been concerned with the problem of DV for some time, and have led in the initiative to make screening for DV a GRPA requirement. As an extension of their efforts to identify victims of DV and increase outreach to this segment of the patient population, they had earlier examined the medical records of a random selection of 100 female patients and found that 58% of these women were identified as victims of some sort of DV. This information has proved useful in discussing the severity of DV on the Warm Springs Reservation, and has been employed as part of educational and grant writing activities. The attempt herein is to look at a select number of medical problems in the same patient sample, in order to gauge what variations in medical problems exist between those with a history of DV and those who have not been victims of DV. The hope is that this information can also be used in expanding educational efforts regarding DV and its comorbidities. Obesity and the metabolic syndrome in Madras, OR Project Date: 1/2/2006 Although attempts at weight reduction are common in the United States, the prevalence of obesity has increased at an alarming rate since the 1980s. In this study an attempt was made to calculate the prevalence of obesity as well as comorbid conditions contributing to the metabolic syndrome in a Madras, Oregon family practice clinic. All patients over the age of 35 who entered during the course of a week were weighed and measured and had BMIs calculated. Their charts were reviewed for comorbid conditions including known cardiovascular disease, diabetes, hypertension, and dyslipidemia.. Patients were categorized as healthy weight (BMI = 18.5-24.9), overweight (BMI = 25-29.9), or obese (BMI > 30). Of 62 patients, 17.7% were of healthy weight, 33.9% were overweight, and 48.4% were obese. Additionally, 21% of patients evaluated met criteria for the metabolic syndrome, a cluster of clinical and biochemical abnormalities associated with the onset and progression of atherosclerotic cardiovascular disease. Increasing Awareness and Screening of Postpartum Depression in Klamath Falls Project Date: 10/17/2005 Postpartum depression occurs in approximately 10-22% of women nationally. Risk factors for developing postpartum depression include being a single parent or in an unstable relationship, living at a lower socioeconomic level and having a lack of social and emotional support. Given childbirth is considered such a joyous time in a woman's life, having symptoms of depression can cause women to feel guilty or ashamed. As a result, postpartum depression is under-reported and often physicians do not readily inquire about it. It is an important illness to recognize because not only can it be debilitating for a woman, but it can interfere with essential maternal-infant bonding and can have long-term consequences for the child such as behavioral, cognitive and social developmental problems. Many women in Klamath Falls become mothers at a young age and lack financial resources, stable relationships and emotional and social support. Based on these displayed risk factors, one can infer that postpartum depression is a problem for some women in Klamath Falls. It is therefore important for women to be informed and adequately screened for postpartum depression. As a community project, postpartum and pregnant patients were surveyed to assess the need and interest for more information and screening for postpartum depression. Similarly, several doctors were consulted and expressed interest in providing women written information on postpartum depression and better access to a definitive screening tool. Based on this feedback, an educational pamphlet was created for women with information on understanding the disease, recognizing the symptoms, and knowing the treatments and was made available in the clinic. Similarly, a screening tool specific to postpartum depression was made accessible to the doctors in the clinic to facilitate more consistent screening. Prevalence of depression and effectiveness of treatment modalities at OHSU Scappoose Clinic Project Date: 7/4/2005 Depression is a common reason for primary care visits. Many patients suffering from depression incur tremendous emotional, physical and financial hardship making it an important topic to address. Treatment of patients with depression can be difficult because of patient's compliance, high rate of relapse and tendency to become chronic. However, studies have been done showing that a comprehensive approach for treatment of depression is both cost effective and increases patient's sense of well-being. Morever, the purpose of this study is to estimate the prevalence of depression at OHSU Scappoose Clinic and specifically look at types of treatments received, duration of treatment, which methods of treatment worked best and whether patients felt they had access to care. Methods: A survey was drafted that asked specific questions about duration of treatment, types of treatment received, treatments that worked best, age and sex, and access to care. The patients were handed a survey before appointments with nurse practitioner, physician assistant and physicians, and were given time to fill it out. This was done for a week's duration. Results: A total of 53 people were surveyed; 41 females and 12 males. Of those surveyed a total of 25 were depressed; 21 (51%) females and 3 males (33%). No significant difference in average age and duration of therapy was found for males and females. Drugs and combination therapy were used equally as frequent and 6 patients, 2 males and 3 females, said no method of treatment worked for them. Only 2 out of the 25 patients said they felt like they had no access to treatment. Conclusions: A considerable amount of patients at OHSU clinic with depression are not receiving care that works for them. A recommendation to make treatment of depression more comprehensive and conducive to the patient population will increase quality of care received at OHSU Scappoose Clinic. Bipolar Education in Klamath Falls Project Date: 7/4/2005 Current prevalence estimates of bipolar disorder in the pediatric population are thought to be about the same as those in the adult population, approximately 1%. Existing evidence indicates that bipolar disorder beginning in childhood or early adolescence may be a different, possibly more severe form of the illness than older adolescent- and adult-onset bipolar disorder. Recently, as the understanding of childhood bipolar disorder has grown, provider education about bipolar disorder has increased the rate at which diagnoses occur. With this large rise in the number of bipolar cases, physicians need to utilize all resources available to help them treat their patients including the patients themselves. The purpose of this project was to improve patient education about their disease. To accomplish this a survey was conducted of current patients and their parents to determine their current knowledge of the disorder. Reporting on these questionnaires showed that all parents sought out alternative resources to fill gaps in their knowledge. Information from the questionnaire was used to help in the creation of an educational brochure about bipolar disorder. This document was given to the Klamath Pediatric Clinic for distribution to current and future patients. Mental Health and Addiction services are vital component of our communities. Project Date: 4/25/2005 Mental health and addiction services are vital components of our communities. In my short time at the OHSU Scappoose Family Practice (SFP) Clinic, the tremendous amount of mental health and addiction issues within the patient population became readily apparent. This project focused on identifying the major mental health and addiction resources within Columbia County, the county which is home to the OHSU SFP Clinic. Additionally, this project attempted to strengthen the ties and communication between those mental health resources and the practitioners at the OHSU SFP Clinic. The data was obtained through interviews with Columbia Community Mental Health (CCMH) and OHSU SFP Clinic staff members. As a result of the interview with the Executive Director of CCMH, a listing of services provided by CCMH was created and distributed to OHSU SFP Clinic staff. In addition, the framework for efficient and effective long-term communication (about patients, resources, etc.) between the two entities was constructed. Single Parent Support Group Project Date: 3/21/2005 The United States is home to approximately fifteen and a half million single parents.1 Studies have demonstrated the risk of onset of depression among single parents is double that of their married counterparts with social and financial support being significant variables influencing depression2,3 The large number of mental health problems seen in primary care clinics makes this issue a commonly addressed complaint. This study attempted to identify single parent patients suffering from depression and evaluate the effectiveness of a social support group in helping to reverse their depressive state. The design was recognition of depression in single parent patients and then introduction of these patients into a group of other single parents within their community allowing social interactions and self-determined topics of discussion. While identifying single parents suffering from depression or those who simply had interest in participating in the support group was easily done, there was no existing support group in the community for single parents. Therefore the final product of this project was development of bimonthly support group for single parents with the goal to eventually incorporate family activities, a baby sitting cooperation and educational activities. Parents were encouraged to bring their children with the secondary goal of providing a safe environment for the children to interact with others in similar family structures. The group met for two hours twice during the five week rotation. In addition to self-directed discussion the group was provided with literature addressing various topics regarding parenting techniques, community resources, and self-help motivational information. The effectiveness of the social support group was evaluated by an anonymous survey provided after the second meeting. Mental Health Resources in Clatsop County: A Summary of the Need For and Existing Mental Health Services Project Date: 3/21/2005 Mental health disorders and the need for mental health services are pervasive in all areas of Oregon, including rural communities like Clatsop County. Residents of Clatsop County have a greater proportion of alcohol and drug-related problems and have at least equal to or greater need for other mental health services. Despite the need for mental health services, resources are seemingly lacking, and furthermore, resources are not readily evident to local health care providers who must often align their patients with appropriate mental health services. The goal of this project was to examine the scope of the need for mental health services in Clatsop County, identify mental health resources in Clatsop County, formulate a pamphlet for use by local health care providers and community members which summarizes existing mental health resources, and approximate whether current resources adequately meet the needs of the population with mental illness. Suicide in Harney County: Is it higher than metropolitan Portland? Project Date: 3/21/2005 Suicide is a significant medical issue in the rural United States. This study compared the suicide rate in rural Oregon with more urban areas of Oregon from 1998-2004. It also attempted to answer the question of why the rural suicide rate is higher than urban areas. The design was retrospective review of Oregon vital statistics grouped by counties. Counties were separated into groups according to population. Mean yearly suicide rates for each group were calculated as well as overall suicide rate per group during the time period from 1998-2004. Statistics for variables thought to be associated with suicide rate were also obtained and compared to the group suicide rate in an attempt to determine if any relationship exists. Calculated suicide rates were generally higher in Oregon's rural counties than in urban counties. There was also a difference between the most rural and most urban counties in each variable obtained, however there did not appear to be a trend when looking at all groups by increasing urbanization. Therefore, there does appear to be an increased suicide rate in rural Oregon counties which is consistent with other rural areas worldwide, however no definite risk factors were identified. Gambling in John Day, Oregon: Creation of a Patient Brochure. Project Date: 2/7/2005 Gambling is a prevalent problem both nationally and in Oregon. It can have wide-ranging effects, including those on finances (like bankruptcy), higher rates of receipt of past-year unemployment and welfare benefits, arrest, incarceration, divorce, poor or fair physical health, and mental health treatment. Despite this prevalence, it is not routinely screened for in a family practice clinic in John Day, Oregon, and there is no current patient information brochure here addressing it. The purpose of this project was to develop a patient information brochure to address gambling in one rural Oregon family practice clinic. The patients of this clinic were the target population. Data was gathered by speaking to the clinic’s provider as well as a gambling counselor regarding the negative effects of gambling and things to include in a brochure. An extensive Internet search was also undertaken to gather information. This data gathering yielded the creation of a brochure that included the following information regarding gambling: basic statistics, forms and locations in which it takes place, negative effects, common myths, screening questions, and treatment resources. If there were more time in the clerkship it would have been beneficial to try and observe whether the brochure prompted any discussion between patient and provider, as well as to try and contact other providers in the area to see if they would like to display the brochure in their offices. The Impact of Alcoholism in Tillamook County and the Resources Available for Alcoholics. Project Date: 2/7/2005 Unhealthy alcohol use can be associated with multiple economic, social, and medical problems. This project will assess the impact of alcoholism in Tillamook County and assess the resources available for alcoholics. To assess the impact of alcoholism, community members who were dealing with alcoholism either directly or indirectly were interviewed. Statistical information was gathered by the Oregon DHS, National Institute of Alcoholism and Alcohol Abuse, and Oregon Crime Data websites. According to the Oregon Department of Human Services, the rate of adult alcohol abuse or dependence in Tillamook County is roughly similar to the state average (7.5% vs. 7.8%). The rate of alcohol related arrests in Tillamook County is significantly higher than the state average (182.5 vs. 48.6 per 10,000 in 2002) however, and this might be attributed to the influx of tourism during the summer and the lack of public transportation in the evening and taxicabs. However, in a 2004 survey, the rate of binge drinking among North Coast County (Tillamook, Clatsop, Columbia) eighth graders, the rate of binge drinking was 39% versus 29% statewide. A barrier to treatment in Tillamook County is a lack of a formal detox center. Individuals hoping to detox must drive over one hour away either to Lincoln County or Portland. However, there are also some great resources available as well, including AA, which has 21 meeting times a week and Tillamook Family Counseling Center, the primary mental health and alcohol/drug service. Physicians can take a proactive approach by screening patients with the AUDIT questionnaire, engaging in brief interventions, and providing medications when necessary. Assessment and Treatment of Acute Psychiatric Disturbances in Madras, Oregon Project Date: 1/3/2005 A review of medical records in the Madras Mountain View Hospital over the past year reveals that physicians in Madras, Oregon are not managing psychiatric emergencies up to the standards that they are capable of meeting. For instance, physicians in the Madras Medical Group are placing acutely psychotic patients in restraints or seclusion 61% of the time. This is significantly more than the 20% of time that experts find these measures appropriate. This difference is not likely a reflection of a threefold increased number of psychiatric patients in Madras compared to the rest of the country. Rather, it more likely reflects the fact that the psychiatrically ill population of Madras is not being appropriately cared for in emergent settings. In fact, experts would consider 60% of “holds” in Madras inappropriate. Fifty percent of patients placed in the Madras holding room did not even have a physician-documented psychiatric evaluation in their chart. The primary reasons for these problems are the limitations of a rural setting, increased level of complexity involved in emergent behavioral care, and rural physician discomfort with their acting role as psychiatrist. Madras does not have even a single community psychiatrist. These factors indicate that the Madras Medical Group would benefit from a review of appropriate delivery of acute psychiatric care. Specifically, an approach that better balances the rights of patients with considerations of safety and good standard of care is presented here and contrasted with the current level of care in Madras. Recommendations for improved assessment, charting, and intervention are offered. Furthermore, an outline of appropriate pharmacological treatments is provided. The Idiosyncrasies of Rural Mental Health: Taking a closer look at women's perceptions of available mental health services, as well as their own psychosocial risk factors, Grant County, OR. Project Date: 10/18/2004 Mental health disorders are a major public health concern in the United States. Although access to services can be limited in rural areas, this study attempted to explore both perceived barriers to mental health care, as well as personal psychological and social risk factors that may affect emotional well-being. A survey was devised to address three categories: (1) the impact of psychosocial risk factors, (2) perceptions of local mental health services, and (3) the role of the rural doctor in treating mental illness. Because of their statistically increased risk of experiencing depression and anxiety, women eighteen and older were identified to complete this survey. Results showed that although women in Grant County tend to have a low severity and frequency of identified risk factors, they have a considerably low self-esteem. This is particularly evident amongst the surveyed elderly population. While this may not directly contribute to mental illness, it can increase vulnerability to those already at risk. Women appear to be accessing mental health services as needed, and generally perceive their family physician to be an additional good resource. This emphasizes the central role that primary care doctors play in rural mental health. Mental Health: Breaking Down Barriers to Mental Healthcare in the Philomath Area Project Date: 10/18/2004 Mental illness is common across America and this may be most apparent in primary care clinics. Primary care physicians have become a significant focal point to mental healthcare delivery everywhere, but especially in rural communities where community mental health resources are lacking. This report assesses the prevalence and disease burden of mental illness in the U.S. overall, in our rural communities, and in Benton County. Secondly, it discusses the barriers to mental healthcare and the role of the primary care physician for mental healthcare delivery. Thirdly, it evaluates the community mental health resources available in the Philomath-Corvallis area, as well as how the physicians of Philomath Family Medicine are utilizing these resources. Finally, from the information gathered by survey of the community, and physician and therapist interviews, a consolidated list of community mental health resources was produced, including contact information, description of services, eligibility and cost. The ultimate goal is that these lists will promote more effective utilization of community mental health resources in the Philomath area. Japanese Healing Gardens Project Date: 8/9/2004 The negative effects of stress and anxiety have been well documented in past research and effect psychological, physiological, and behavioral health. Many find hospitals to be complex, confusing, and anxiety-inducing environments, imparting a sterile, institutional vibe to patients and staff. This observation has led architects, psychiatrists, neuroscientists, and health care workers to collaborate on a movement behind “evidence based design.” They promote their research findings that show that environment does effect health, and changes in hospital design can be followed by improved patient outcomes and increased staff satisfaction. As stress and anxiety levels fall, patients and staff feel and do better. A leading investigator in the field, Roger Ulrich, found that positive distractions, such as nature, are especially helpful. He found that patients recovering from surgery with a window view of nature have shorter recovery times, request decreased dose and strength of pain medication, and have fewer post-op complications. Incorporating nature into hospital design has also been shown to improve staff satisfaction and staff turnover, attract more patients, and increase charitable donations. Lebanon Community Hospital is currently in the midst of construction of a Japanese Healing Garden. Many patients and staff are uncertain as to the purpose and usefulness of such an undertaking at a time when resources are in short supply. Thus, I decided to focus my community –oriented primary care project on investigating the topic of healing gardens, including the evidence behind constructing healing gardens in healthcare settings and measurable patient outcomes. Japanese gardens are specifically addressed, and the symbolism involved, in order to more fully explain the components of the LCH garden. Lastly, a few suggestions are made to avoid problems encountered by other facilities, as well as an effort to generate ideas for a research project to monitor the effect of the healing garden on patient and staff. Prevalence of Eating Disorders in a Klamath Falls Pediatric Clinic Project Date: 8/9/2004 Eating disorders represent a significant cause of morbidity and mortality and typically present in adolescents and college-aged young women. Pediatricians have a unique opportunity to detect and treat these disorders.6 At the Klamath Pediatric Clinic it was noted that a large proportion of the visits were for mental health, however none of these were for the treatment of eating disorders. The purpose of this study was to specifically screen for eating disorders to determine if the prevalence was low or if the disorders were not being identified. A screening questionnaire was developed and given to patients at the clinic aged 10 and over, over a two week period. None of these patients screened positive for anorexia or bulimia, however the prevalence of obesity appeared to be fairly high. In addition, a brochure was developed to use as an informational and screening handout for concerned patients and an initial assessment form was made to use for a patient presenting with an eating disorder. I also visited the mental health treatment center for the area, which had the ability to provide outpatient treatment for eating disorders. The effects of Chronic psychological stress Project Date: 5/10/2004 The relationship between psychological stress and overall general health has been well documented in many studies. Chronic psychological stress can elicit negative health effects on numerous organ systems including the immune, gastroenteral, and nervous systems. The hope for this study, via questionnaire, was to examine the prevalence of stress in a small community primary care clinic, the perception of stress and its affect on general health, how often measures are taken by patients in order to decrease chronic stress, and to identify examples of major stressors that affect the community. Furthermore, it was hoped that this study would shed insight to what degree a primary care physician can identify stress and its symptoms as well provide information in stress lowering activity. I found that 31% of the respondents indicated mild to moderate stress and 17% of patients had significant stress. 23% of respondents had severe stress levels. 28% of patients felt that stress had little or no effect on general health. Furthermore, 29% of patients indicated they never take steps to reduce stress. Examples of stressors that were listed in the survey varied in sources. These data suggest stress is substantially present in this rural community. A need to address the health concerns that may be associated with increased levels of stress and careful inquiry by primary care physicians into potential stress would likely benefit the management of patient health issues in a rural community. Identifying and addressing stress related symptoms would likely yield many benefits, i.e. productivity at the work place, increased coping strategies, etc. ADHD vs. Bipolar Affective Disorder: a Comparison of the Two Mental Health Problems in the Pediatric Population of Klamath Falls. Project Date: 5/10/2004 Mental illness is an important medical problem in the pediatric population that affects communities ranging from large metropolitan areas like Portland to small towns such as Klamath Falls. Although the prevalence of attention deficit hyperactivity disorder (ADHD) and bipolar affective disorder (BAD) are significantly different in the pediatric population, they are often confused with one another due to the overlap of common symptoms. Therefore it is important to identify children with these disorders and make an accurate diagnosis to ensure that they receive the proper medical and psychological treatment. Analysis of ICD9 codes from 2003 demonstrated almost 1,000 visits for ADHD and BAD at The Klamath Pediatric Clinic. These numbers were confirmed by my own record keeping during a three week period which showed 16% of all visits were for mental health issues. Given the number of patients with ADHD and BAD, a screening tool was utilized to try to find differences in the presentation of these two illnesses at the time of diagnosis. Results from questionnaires handed out in the clinic showed higher scores by patients with BAD (24 versus 15; p 0.011). In addition, three specific categories including irritability, thought content, and disruptive behavior were significantly higher in children with BAD. The results of this project suggest that mental illnesses, specifically ADHD and BAD are an important healthcare issue at The Klamath Pediatric Clinic and that there may be ways to better screen for and treat these patients. Mental Health: Coordination of Care in Josephine County Project Date: 5/10/2004 Access to and delivery of mental healthcare in rural America is a significant problem. According to the primary care providers (PCP) in Josephine County, OR, this is one of the most frustrating aspects of their practices. The family practice physicians felt that Josephine County Mental Health Department (JCMHD) was not adequately taking care of the mental health needs of their patients. JCMHD felt that they were doing a reasonable job of this and that their policies and procedures were well thought out and implemented with the blessing of the directors of the local independent physician associations (IPA). This project attempted to improve communication and understanding between the JCMHD and local PCPs in the area in order to help bridge the impasse that had festered. Multiple interviews were held with administrators at JCMHD and local PCPs as well as the director of one of the two local independent physician associations. Through these discussions, a proposal was made to the local IPA and JCMHD. The proposal includes four parts: 1. Same-day call back to the local PCPs from the psychiatrist. 2. Prompt feedback from the therapists after the patient’s initial visit either through a phone call or a fax. 3. Urgent slots with the psychiatrist will be made available for acute patient care. 4. A meeting to be held every four months with representatives from JCMHD as well as the directors of the two local IPAs. The local IPA is on board with the proposal and JCMHD is still reviewing the proposal, but seems willing to agree to it as well. Screening for depression in the elderly Project Date: 5/10/2004 Objective: To evaluate depression among individuals over the age of 65 presenting the primary care setting. Methods: The 15 Geriatric Depression Scale (GDS) was distributed to both Spanish and English speaking patients in the primary care setting. The question also included demographic information to identify possible risk factors for depression in the community being evaluated. One community's response to a chronic shortage of psychiatrists: Telepsychiatry Project Date: 11/10/2003 In Ontario, Oregon, one major issue in the access to psychiatric care and in the continuity of that care is a paucity of mental health providers. This project considers one alternative currently in use in the community-telepsychiatry. Telepsychiatry is effective and convenient in appropriate populations. Interviews of employees of two of three mental health agencies serving the Ontario region were conducted, exploring use of telepsychiatry. The correctional institution in Ontario provides mental health services to inmates by teleconferencing equipment based in Ontario and Portland, Oregon. This is a successful mode of treatment, delivering increased access to care, increased public safety and patient satisfaction. The community psychiatry agency in Ontario, Lifeways, utilized telepsychiatry until costs overcame that effort. They were informed about the Federal Commmunications Commission's support for rural telemedicine efforts. Mental Health Services in Grant County: Challenges & Progress Project Date: 8/18/2003 With budget cuts limiting the availability of services for mental health, small rural communities like Grant County are the hardest hit. The central goal of this project is to provide an initial framework of the nature of mental health services that exist in Grant County. The design for this project includes internet searches via the DHS website and an interview with the director of mental health services at the Center for Human Development. Grant County Center for Human Development is located in John Day, OR. It is the only place in the county that specifically provides mental health services. Yet, Grant County has a population of approximately 8000 people. As a result there is limited access to mental health services. However, other significant challenges include a limited staff, of which an overwhelming percentage is not appropriately trained to properly handle assessment and treatment planning. Furthermore, the study reveals that there is poor patient management and a laid-back approach to intervention. The encouraging aspect of the study is that the staff is receiving more training, a crisis worker has just recently been hired, and an improved method of documentation is being devised to better manage patients and the course of their treatment outcomes. Future plans call for the establishment of a psychiatric emergency unit in Grant County and contributions from residents and medical students in terms of sharing their time and knowledge with the mental health department staff in an effort to improve the quality of mental health services in Grant County. Elderly Suicide in Coos County, OR Project Date: 7/7/2003 In the United States, one elderly person commits suicide every 99 minutes. Suicide rates among the elderly are increasing nationwide. Coos County has a higher suicide rate than that of the U.S. as a whole and that of Oregon, a statistic at least partially explained by the county's higher proportion of older people. The problem of suicide in Coos County became particularly apparent this year when over a 35-day period between May and June seven elderly residents took their own lives. The majority of elderly people who commit suicide are in regular contact with a physician-75% have seen a primary care physician within one month of their death. This project attempted to address the relatively underappreciated issue of elderly suicide by increasing physician awareness of the problem via a fact sheet and resource guide. The guide was distributed to physicians in Coos County and contains statistical data on suicide in Coos County, specific information regarding the recent cluster of suicides, identified risk factors for and facts regarding suicide in the elderly, and a discussion of potential prevention strategies. Biomedical and cultural factors in suicide etiology are discussed. The objective in development of the guide was to increase physicians' index of suspicion for this significant cause of mortality. The Potential Benefit of Electronic Medical Records In the Management of Chronic Illness: A Case Study of Coronary Heart Disease and Depression in Lebanon, Oregon. Project Date: 3/24/2003 In recent years electronic medical records (EMR) have become an increasingly important part of documenting and providing medical care. In addition to saving money, reducing errors, and improving documentation, EMRs can potentially improve patient health by allowing physicians to better monitor patient progress and increase information access to patient populations. This report was designed use a patient population in Lebanon, Oregon as a case study to gain an understanding of how EMR could affect the care provided for a chronic medical condition. The paper charts of 62 admissions (97% of the total) coded for acute myocardial infarction at Lebanon Community hospital for the year 2002 were selected as markers for coronary heart disease (CHD). These were reviewed to determine the prevalence of a comorbid diagnosis of major depression or medical treatment of depression. Depression is a major risk factor for increased severity and mortality in cardiac events, therefore managing depression can have a significant impact on patient outcomes. This study found that 15-19% of patients hospitalized with an acute myocardial infarction were either diagnosed or being treated for depression. However due to systemic barriers it was difficult to efficiently assess patients’ long- term history and to evaluate whether depression in these patients was successfully being treated. This was because information was often missing from charts, hospital and outpatient records were not integrated and documentation was often incomplete. The Samaritan Health System that provides care in Lebanon is part of a network of five hospitals and 21 outpatient clinics. This system would likely receive more benefit from an EMR through greater efficiency and better quality control and decision-making support than the initial cost of installation, training and conversion of old records 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. Nutrition and Fitness: Development of a Program to Supplement Physician Intervention in Management of the Health Risks of Obesity. Project Date: 12/30/2002 Obesity and its many associated health risks is a growing problem in the United States. This study attempted to identify strategies for physicians to increase their effectiveness in promoting dietary modification and weight loss for overweight patients at a family practice clinic in John Day, Oregon. The design was observation of physician interaction with overweight patients motivated to lose weight, and one on one dietary counseling with self selected patients. Community resources available for patients include a dietitian who visits the community monthly, and a new fitness center. Additionally patient handout availability and effectiveness was examined. While the physicians were actively discussing the importance of diet and fitness with their patients, time limitations prevented adequate follow up. Many patients expressed bewilderment at the amount of different diet information available via the popular press. Patients requested basic, simple guidelines to help them start meeting their weight loss goals. Handouts currently available at the clinic are from the American Heart Association, and while quite comprehensive were described as “confusing” and “overwhelming.” The final phase of this project thus involved the creation of a short, simple handout that outlined suggested dietary modifications for weight loss. Alcohol Abuse/Dependency Treatment in Harney County: An informal Survey of Available Services Project Date: 9/23/2002 Alcohol/ substance abuse is a significant problem in rural communities, particularly in times of economic downturn. This project is an informal survey of services available in Harney County for alcohol abuse and how the different branches of the health care community communicate and respond to this issue. Personal interviews with the clinical directors at Harney Behavioral Health and Harney District Hospital as well as an administrator at the Sheriff’s Department and a counselor at the Indian Health Service were conducted at various times throughout the clerkship. From these interviews, a barrier to accessing mental health services was identified. Patients seen in the ER after hours for Substance abuse related health problems were not being referred to mental health services for substance abuse disorders. As a result of this observation and subsequent interview with the clinical director at Harney Behavioral Health, renewed efforts at improving communication between the hospital and HBH are being made. This will take the form of HBH sending a representative to monthly staffing meetings in order to network and increase access to mental health services. Providing a home: a place for children with special health care needs Project Date: 8/12/2002 Pediatric and adolescent patients currently have limited resources for obtaining mental health care and counseling. Three primary reasons exist for this lapse in health care. These include having only one option for Medicaid patients, the social stigma associated with going to a mental health care clinic, and limited physical accessibility. For all these reasons, these children do not obtain treatment or counseling. Another issue that has resulted in fragmented and incomplete care is the lack of communication and coordination between mental health care providers and the primary care physician. Treasure Valley Pediatric Clinic in Ontario, Oregon has become acutely aware of the shortcomings of the mental health care that is offered in our community. Nationally, children with special health care needs constitute 16-18% of all children. A low estimate shows that in the last three months alone, 14.7% of office visits at Treasure Valley Pediatric Clinic comprise seeing CSHCN. In trying to provide complete health care to children, the American Academy of Pediatrics developed the concept of the medical home. In an effort to meet the ideals of the medical home, TVPC presently employs a care coordinator. Unfortunately, this does not address many of the concerns facing mental health care in this community. TVPC wants to expand the medical home by incorporating mental health in a neutral and comfortable environment within the pediatric clinic where routine care is provided. In doing so, TVPC strives to provide accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally competent health care to children with special health care needs. Mental Health Service in Florence, Oregon Project Date: 3/25/2002 Throughout my limited interview sessions with the mental health providers, I was repeatedly reminded of the superior mental health coverage in Lane County. Unfortunately, I have not obtained data to support this claim in quantifiable terms. Instead, this project aims to highlight the two agencies that provide mental health services to Florence: namely, the Siuslaw Pacific Center and Peace Health Counseling Services. More importantly, while I attempt to demonstrate how these two agencies function as an integral part of mental health provision in Florence, I would also highlight the differences between the two such that they work in complementary ways. 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. Staying Active and Correlates to Geriatric Depression in Florence. Project Date: 9/24/2001 An attempt was made to understand the nature of geriatric depression in a small coastal town in Oregon. The study was originally formulated with the hypothesis that a casusal link exists between lack of meaningful social activity and depression. Patients 65 years and older that have been diagnosed at one time with depression were selected from among the patients of a local internal medicine physician. These patients were interviewed in depth about their present and past level of involvement in social activities, limitations on participation in activities, degree of social isolation, living situation, palliative/aggravating factors, and use of antidepressant medications. Following the interviews, the link between level of activity and depression was found to be complex. As a supplement to the study, a detailed list was compiled of area services for seniors, meal programs, interest and support groups, social activities, and volunteer opportunities. This information was organized into a pamphlet, which was mailed to those participants that indicated interest. It was also made available to staff in the physician's office and to discharge planners at the local hospital. The Detection and Treatment of Depression in Post-Myocardial Infarction Patients in Baker County, Oregon Project Date: 9/24/2001 Depression is common in patients recovering from a myocardial infarction. Approximately 1 in 6 patients with MI experience major depression and even greater numbers experience significant depressive symptoms following the event. Post-MI depression is an independent risk factor for angina, ventricular arrhythmias, future myocardial infarctions, and mortality following MI. However, given the acuity of the event, depression may often be under-recognized while diligently managing the patient's acute medical care. This study was designed to ascertain the detection rates of post-MI depression in an internal medicine clinic in Baker City and subsequent treatment practices and mortality. This study compared the prevalence of depressed post-MI patients in this Baker clinic to that of multiple national studies in which patients were comprehensively screened for depression following MI. National post-MI screening revealed a prevalence of depression between 16-23%. The documented Baker rates of depression following MI were 14.6% over the last three years, and 7.7% during the past year. However, the Baker general patient population had a lifetime prevalence of depression of 16%, comparable to the national average of 15%, indicating that depression in the post-MI patient population may not be recognized at the same rate. Regarding treatment of depression in patients at risk for MI, several studies suggest that the use of Tricyclic antidepressants is contraindicated, as they may potentiate a Class 1A antiarrhythmic effect leading to increased risk of mortality. In its place, selective serotonin reuptake inhibitors are now being recommended as first-line treatment for post-MI patients not only due to decreased cardiac side effects compared to older antidepressants, but also due to its inhibition of platelet activation. In the Baker City clinic, all documented depressed post-MI patients were treated pharmacologically. One third of the patients were treated with an SSRI alone, another third were treated simultaneously with an SSRI and a tricyclic (usually for another simultaneous condition such as chronic pain), and the last third were treated with antidepressants from other classes. Despite the use of TCAs in some of these patients, none of the depressed patients suffered mortality or a recurrent MI in the last 3 years. Although post-MI patients are being successfully detected and treated for depression, an improvement can be made in identifying more at risk patients and reconsidering the use of TCAs in this population. Back to subject search page or search by preceptor site