RCHC Community Project Abstracts

Back to subject search page or search by preceptor site The Strawberry Wilderness Community Clinic: A Patient Centered Medical Home for the people of Grant County? Project Date: 10/12/2009 The Patient Centered Medical Home (PCMH) is a model of care gaining support in the primary care community as a delivery system focused on coordinated, comprehensive health care and the patient experience. As health care reform in this country pushes to make improvements in quality and safety, the PCMH may become an ever-more-relevant piece of the healthcare puzzle. However, transitioning to this model from the current fee-for-service model requires time, money, and a coordinated effort by all levels of staff to change some of the fundamental pieces of the health care delivery system. Is this transition feasible in a small, rural practice like the Strawberry Wilderness Community Clinic (SWCC) in John Day, Oregon? How well does SWCC already provide a PCMH for its patients? What are some of the barriers that SWCC (and presumably other small rural health clinics) face in providing this type of health care and what are some ways in which SWCC can move toward providing a PCMH in the future? This study attempted to address these questions via interviews with clinic staff along with a survey developed to assess patient satisfaction. Results of the interviews were qualitative in nature and produced information regarding quality measures, information technology and practice organization at the SWCC. The patient survey generated 25 responses, producing quantitative information on the patient experience and access to healthcare. It was determined that SWCC provides some aspects of a PCMH, mostly with regards to the patient experience, but struggled to meet most of the quality measures associated with providing a PCMH. The biggest barrier appeared to be a lack of trained staff to do data collection or analysis on the quality of health care and health outcomes at SWCC. There were many suggestions for future improvement. A Welcome Home: Needs Assessment and Projected Cost Analysis of the Addition of a Behaviorist to the Primary Care Home in Florence, Oregon Project Date: 9/8/2008 According to a 2002 study published in JAMA, “Most people in the United States want a medical home.” As the PeaceHealth Siuslaw Region Family Medicine practice makes plans to move forward with its version of a Primary Care Home, a needs assessment and a projected cost analysis were performed to determine the probable clinical and financial outcomes of adding a behaviorist to the care team. The design of this study was direct observation of the practice of one of the ten family physicians currently working at the PeaceHealth Family Medicine Center. At the conclusion of each working day, the patient census was analyzed; based on presenting complaints, chronic health problems and length of individual visits, we sought to determine which patients would have benefited from a consultation with a behaviorist. Based on average Medicare and Medicaid reimbursements for both physician office visits as well as Health and Behavior codes, we were then able to estimate the projected financial impact of these determinations. Our findings demonstrate that a behaviorist is a necessary and, in the worst-case scenario, a cost neutral addition to the Primary Care Home in Florence, Oregon Enhancing Diabetes Care Project Date: 6/30/2008 Diabetes mellitus type II is nearing epidemic numbers in the United States, straining our healthcare delivery system. A complicated disease to manage, diabetes poses a particular problem for rural hospitals and providers who may lack the resources or continuity available to urban patients. Blue Mountain Hospital in John Day, Oregon has addressed the problem of complicated inpatient management, in part, by creating standardized admission and discharge orders for complicated problems. This project aimed to enhance diabetes care at BMH by adding admission and discharge order sets that any provider may use to streamline admission and improve the hospital course. In addition, patient education materials were found and provided. Due to low patient volume, the orders have not yet been used, but received positive feedback from practitioners, hospital staff, and the director of nursing services. 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. The Effectiveness of Patient Education in the Total Health Community Clinic: A Media-Based Approach Project Date: 2/11/2008 Patient education is a key component of preventative medicine and is necessary to providing comprehensive patient care. This student attempted to identify the effectiveness of patient education efforts in Monmouth, Oregon family practice clinic. The design included observation of patient education methods currently in use in the clinic and an analysis of the effectiveness of those methods over the course of four weeks. In addition, patient interviews were conducted to both assess the effectiveness of patient education methods currently in use and to discuss methods for improvement. New methods for educating patients were then employed and their effectiveness measured via observation and patient feedback. These included patient educational videos presented in the waiting area as well as patient handouts. In addition, a patient-accessible computer with learning tutorials was proposed to clinic administrators and approved for implementation. The changes achieved in this project enhanced patient education and increased satisfaction with the clinic waiting room experience, as many patients felt that their waiting time was more valuably used. Recruiting and Retaining Physicians in Coos Bay: Assessment of Medical Student Interest in Rural Medicine and Rural Physician Perspectives on Their Practice Project Date: 2/11/2008 Background. Coos Bay is a rural city on the southern Oregon coast that struggles to recruit and retain sufficient physicians. The purpose of this study is to assess medical student rural interest and Coos Bay physician perspectives as they relate to recruiting and retention. Methods. A literature search was conducted to identify common recruiting and retention issues. Physician recruiters and practicing physicians at NBMC were interviewed to identify unique issues and their commitment to this community. Finally, OHSU medical students were surveyed to assess their past and current level of interest in rural medicine. Findings. Key to physician happiness in is their practice. Most of the physicians interviewed are planning on retiring in Coos Bay. Medical student rural interest correlates with increasing student age, male gender, and rural upbringing. Specialties correlated with rural interest are family medicine, emergency medicine, obstetrics and gynecology, and pediatrics. Medical students showed increased rural interest following their rural clerkship. Conclusions. Successful medical practice is key to physician happiness and thus long term retention. OHSU’s third year rural clerkship is a great tool to increase interest in rural medicine. However, it can be further optimized by addressing housing issues, boredom, and misperceptions. Non-urgent Use of Hospital Emergency Services in Grant County, Oregon: The Impact of Primary Care Physicians Fleeing Rural America Project Date: 2/11/2008 Primary care physicians' covering the Emergency Department is almost exclusively seen in rural health settings. While these physicians rarely encounter problems of overcrowding and prolonged patient wait times often seen in larger cities, several issues arise that are somewhat more unique to rural health. One such issue is the direct relationship between the diminishing number of general physicians practicing in rural areas and the resultant overflow of non-urgent patients into the ED. Regardless, it is these same community doctors providing treatment for these patients creating what may be considered a vicious circle. This magnitude of this issue was explored via a questionnaire directed toward patients visiting the rural Blue Mountain Hospital Emergency Department in John Day, Oregon during a three-week period between February 2008 and March 2008. The results of this study showed that nearly 45% of all patients presenting to the ED during this time had initially attempted to address their health care needs in the primary care setting. These patients also encounter 30% higher costs for health care than their counterparts receiving care via their regular physician. Evaluation of chronic pain management patient burden on CEFP clinic, Klamath Falls, OR. Are we simply refilling opioid medications? Project Date: 9/10/2007 Klamath Falls, is a larger than rural community in S. Oregon. However, due to its proximity to other outer lying rural areas, CEFP serves as the hub in the wheel and center of focus for much regional primary care. There is only on Pain Management specialist in Klamath Falls, and this provider does not take OHP. Thus the burden of low income pain management falls mainly on CEFP. Currently many urgent care visits are taken up by medication refills and frustration of residents in trying to deliver appropriate care is evident. Most notably, loss of professional autonomy is cited by residents in their frustrations in dealing with this patient population. This does not allow for continuity of care and addressing of other patient health issues. In fact these patients are seen more often but with less emphasis on other health maintenance issues. A 6 mos interval of chronic pain management visits was queried from CEFP electronic medical record system. 158 unique patients involving a total of 1075 patient visits in the last 6 mos. These patients were chart reviewed to identify continuity of same provider care and top categorical assignment of other co-morbid health conditions in an attempt to identify strategies to better improve delivery of health maintenance. These results will help the faculty and residents determine if: 1) they are meeting their health care mission to their patients 2) if a pain refill medication clinic is specifically needed to relieve burden on the urgent care practice and allow patient visits to focus more on other health issues. Leadership Interviews Regarding Balanced Scorecards at Lower Umpqua Hospital Project Date: 9/10/2007 Quality improvement is very important in any setting, but especially in a small rural hospital where the surpluses are few, and any lapse in quality may affect community usage & therefore financial viability. The Balanced Scorecard has been proposed as an ideal way for small rural hospitals to strive for quality improvement through the idea that an organization’s mission/strategies and the execution of these are important factors in performance improvement. When Lower Umpqua Hospital joined 19 other rural Oregon hospitals it made the commitment to implement a Balanced Scorecard as way to measure performance against other such hospitals & strive for quality improvement. The purpose of this project is to assess the attitudes, perceptions & beliefs about implementation of a balanced scorecard amongst the leadership at Lower Umpqua Hospital, through key informant interviews. The 5 board members & 6 key administrative staff were interviewed; results were then summarized in an informant report to be used in future strategic planning & board meetings. Medicare Part D in Tillamook, Oregon and Its Implications: Both Financial and Ethical Project Date: 1/2/2006 January 2006 has ushered in a new era in American health care with the institution of the Medicare part D prescription drug benefit. Its promise is to improve prescription drug coverage for seniors. It has been championed as the financial savior for the elderly, but it may pose more problems than it could ever solve. There are actually many cases where the new program hurts the people it is meant to assist. This scenario became evident in a small town, Tillamook, Oregon, during my rural healthcare rotation. In talking with my prceptor, Dr. Parsons, it seemed there were many reasons why Medicare Part D may actually be doing our seniors a disservice. This new drug benefit may also carry with it some ethical issues as well, specifically, is this new program allowing physicians to do the most good for their patients? While Medicare Part D has the potential to ease the financial burden of healthcare for millions, it may pose hidden costs to both seniors and physicians. Medicare Part D Project Date: 1/2/2006 Medicare part D, is a new prescription drug plan being started by the government beginning this year January 1. There is lots of confusion regarding general information, how to sign up, and which plan to choose. This program affects a large amount of the community in Klamath Falls, since all people on Medicare currently are eligible. In addition there are many penalties and nuances of the program. The goal of the project was to find out more information on Medicare D and what it was about, to see the population’s grasp of the new program, and to see what was out there to help those who needed aid. A quick survey was distributed through the practice to see if people knew about Medicare part D. The only community resource in K. Falls was contacted, interviewed, and observed to see what educational opportunities were available to the public. Of the eligible parties only 55.8% were familiar with the new program showing a definite need to further educate those eligible. Success of OHP in Coos County, Oregon Project Date: 1/5/2004 In 1989, the state of Oregon embarked on a controversial experiment in the financing of health care. The state planned to add many uninsured people to the Medicaid program and to pay for this expansion by reducing the Medicaid benefit package -- more people would be covered, but for fewer services. To keep the costs of this policy within affordable limits, the legislature determined that the services provided should constitute a basic healthcare package, and it sought to ensure that Medicaid recipients were, whenever possible, enrolled in managed care plans. This program was titled the Oregon Health Plan (OHP). Since implantation of OHP in 1994, there has been a statewide decrease in per capita health care costs, a greater than 50% reduction in uninsured children, and a nearly 50% reduction for adults. It appears that OHP has improved accessibility of health care in Oregon. The emphasis of my research project was on the impact of OHP on Coos county. Specifically I studied whether OHP has accomplished it’s goal of ensuring adequate health coverage to the people in Coos County and whether accepting OHP patients puts Coos county physicians and clinics at a financial disadvantage? In 1995, Doctors of Oregon Coast South (DOCS) was found in Coos County as a managed care program that would serve the county’s Medicaid population. Since that time, profitability for physicians and access to care for citizens have improved. The project investigates the relative success of the managed care program in Coos county, it’s downfalls and it’s possible future. This investigation reveals that even under a fully capitated managed care environment, the clinic can be successful and the community is well served by OHP. Following is a compilation of information I gathered for this project. Most of this information stem from different sources such as physicians, financial officers and other health care workers. Reports published by Oregon Health Policy and Research have also been used in conjunction with financial data provided by the clinic administrator, and legislative reports. OHP at Work in Rural Oregon Project Date: 9/29/2003 Although Medicaid provides health insurance for millions of Americans, there are problems associated with it that can hinder easy access to quality healthcare. Doctors frequently cite the low levels of reimbursement for services provided to Medicaid patients. Their offices must limit the number of patients on Medicaid in their practice so the higher reimbursement received from private insurers can make up for the losses incurred by treating Medicaid patients. Patients dependent on the government for their healthcare comment that they are not treated with the same respect as other patients, and can have a difficult time finding a physician willing to care for them at all. In 1993, a small group of physicians in Klamath Falls recognized these problems and decided they would takes some steps toward change. That year, Cascade Comprehensive Care (CCC) was birthed in Klamath County as a managed care program that would serve the county’s Medicaid population. Since that time, profitability for physicians and access to care have improved, and for the most part, the patients seem pleased. This project investigates the successes of CCC to present it is an alternative for managing patients on Medicaid. Statewide research is cited to show the relative success of this program, and the results of a survey completed by patients at the Klamath Pediatric Clinic are presented to show the success of this clinic which serves a population with a large contingent of Medicaid patients. Effects Of The Oregon Health Plan In John Day, Oregon. Project Date: 9/24/2001 Since the Oregon Health Plan was implemented in 1990, there has been a statewide decrease in per capita health care costs, a greater than 50% reduction in uninsured children, and a nearly 50% reduction for adults. (1) OHP has clearly made a positive impact on the shape of health care in Oregon. I became curious about the impact of OHP on rural clinics and communities while rotating at Strawberry Wilderness Family Clinic in John Day, Oregon. Does accepting OHP patients put rural physicians and clinics at a financial disadvantage? Has OHP accomplished its goal of ensuring adequate health coverage to the people in rural communities? SWFC has three family physicians and one PA who, along with two other family doctors, provide the entire population of Grant County with primary care. These five physicians see outpatients, manage inpatients, and cover the Emergency department. They are extraordinarily dedicated and possess diverse skills. The sources of my information were varied, including discussions with professionals in various realms of the health care industry, statistics and reports published by the Oregon Health Policy and Research office and AHEC, financial data provided by the clinic administrator, and legislative reports. What follows is a synopsis of the information I gathered. This information leads me to believe that even under a fully capitated managed care environment, the clinic is quite successful and the community is well served by the Oregon Health Plan. Treatment For Hepatitis C In Klamath County Under The Oregon Health Plan: A Novel Local Approach To Care Management Project Date: 9/24/2001 This project seeks to describe an innovative, local clinician-designed, formal managed care protocol and treatment program for hepatitis C patients in Klamath County enrolled in the Oregon Health Plan. Results of the first 6 months of this program are presented , discussed, and compared with a recent study of hepatitis C monotherapy treatment compliance at a VA center. Hepatitis C is a highly prevalent disease whose treatment cost is high. It is estimated that 1.8% of the US population is infected with hepatitis C. According to the results of the 2000 census, approximately 1,148 citizens in Klamath County have been infected by hepatitis C. Since 75% of patients who contract hepatitis C develop chronic hepatitis C with ongoing viremia, approximately 861 patients in Klamath County may have chronic hepatitis C. Interestingly, when one consults the Oregon Health Division website, Klamath County only has one reported cases of hepatitis C from 1995-2000. Back to subject search page or search by preceptor site