RCHC Community Project Abstracts

Back to subject search page or search by preceptor site Factors Associated with No-Shows and Methods for Intervention in a Stayton Family Medicine Clinic Project Date: 9/7/2009 Patients who schedule clinic appointments and fail to keep them contribute to decreased opportunities for patient health prevention and disease monitoring and management, and also contribute to wasted clinic resources and decreased productivity. This project was conducted to identify and describe factors associated with why patients do not keep scheduled appointments, and discuss potential strategies to increase attendance at appointments. Methods: 110 electronic medical record (EMR) patient charts at a Stayton Family Medicine clinic were randomly selected from 442 no-shows identified from 2004-2009. Results: 442(<5%) no-shows were identified from 2004-2009, or about 1 no-show per provider per week. 110 patient charts were reviewed, 45(40.9%) male and 65(59.1%) female. Mean age was 37.4 years old (YO), with 17(15.5%) less than 12 YO, 8(7.3%) 12-17 YO, 40(36.4%) 18-40 YO, 31(28.2%) 40-64 YO; 14(12.7%) over 64 YO. Tobacco use was reported in 61(55.5%) patients, with 6(9.8%) previous tobacco users, 49(80.3%) current tobacco users, and 6(9.8%) recipients of secondhand smoke. The 6 cases of secondhand smoke were children 2-15 YO. Alcohol use was reported in 40(36.4%) patients. Mean number of medications reported was 3.7 and 4.5 for non-tobacco and tobacco users, respectively. Mean number of past medical history diagnoses reported was 4.3 and 6.0 for non-tobacco and tobacco users, respectively. Conclusion: The rate of no-shows at the Stayton clinic is much lower than the average rate found in many studies. Over half the no-show patients reviewed in the study were reported to be smokers. Most patients are relatively young with 59% who were less than 40 YO. Several factors must be considered in deciding which methods to implement to reduce no-show rates among patients. Chronic opiate therapy in the rural setting: special considerations and concerns Project Date: 9/7/2009 Chronic opiate use represents a challenge for rural providers. These patients often have pain with no treatable cause and may be high utilizers of clinical time. In the absence of pain and addiction specialists, it falls to the family doctor to manage these issues. There are many resources available to providers including online pain management recommendations and recently the Oregon Senate recently passed Bill 355 creating a controlled drug database. This project explores the role of this new program in the development of a standardized pain agreement and the management of these patients in the clinic. Medical Marijuana in a Small Town: A Growing Issue Project Date: 9/7/2009 Several states have laws approving the use of marijuana for medical reasons. This requires a special permit and a Doctor’s approval. However, while state government may allow the use of medical marijuana the Federal government still considers it illegal whether for medical use or not. Therefore doctors are wary of discussing or prescribing medical marijuana. Not only do the rules between state and federal government differ, the actual long-term health affects of marijuana is not well understood. For every study that quotes a therapeutic use another shows that long-term use can cause harm. Other studies suggest that marijuana interacts with other medications making it difficult for physicians to know whether the risks of using marijuana outweigh the benefits. Despite these concerns, medical marijuana is being requested by patients more often. This may be more common in certain populations or areas of the state. So not only are the uses of medical marijuana not well understood, the actual number of patients requesting or using medical marijuana is rapidly growing. In my project I will attempt to gain a better understanding of the patients who ask for or use medical marijuana by looking at certain variables such as the reason for requesting medical marijuana, the age, gender and other medications used. An attempt will also be made to estimate the total number of patients with medical marijuana cards in a small southern Oregon rural practice. I also hope to gain more information from clinics that specifically work with patients desiring medical marijuana cards. All this information will be gathered to gain a better, broader understanding of medical marijuana and those who ask for it. Chronic Pain Management Treatment Options Project Date: 4/27/2009 Chronic pain management accounts for a significant number of visits to primary care providers. Effective management of these patients is challenging because of the complexity of chronic pain, the variable efficacy of available treatments, the limited resources of patients, as well as the abuse and diversion liabilities of controlled substances. Chronic pain often incorporates physical, psychological, social and cultural elements. Moreover, these patients can present with multiple co-morbidities and are high frequency health care consumers, both of which contribute to provider fatigue. The present study describes a small sample of chronic pain patients, illustrates current and past pain management strategies and reports current opinions from multiple staff members on the current state of pain management at the Legacy Clinic in St. Helens, Oregon. It concludes by proposing one management option that may improve treatment efficacy and address economic concerns inherent in this common medical problem. Health Literacy at Dunes Family Health Care Project Date: 4/27/2009 Purpose: To determine the prevalence of patients at risk for poor health literacy at Dunes Family Health Care (DFHC), analyze the readability of the patient education materials (PEMs) provided to the patients, and determine what additional steps can be taken to ensure better physician-patient communication. Methods: Health literacy was assessed using the Rapid Estimate of Adult Literacy in Medicine, Revised (REALM-R). The REALM-R was administered to all English Speaking patients or their caregivers, if the patient was >18 years of age, at DFHC. Those who scored <6 were considered at risk for low literacy. Results: One-third of patients were found to be at risk for poor health literacy. Males were more likely to be at risk for poor health literacy. Fifty percent of high school graduates were found to be at risk for poor health literacy. Nearly 90% of those at risk for poor health literacy had completed at least one year of high school or beyond. PEMs at DFHC were written at a mean grade level of 7.4, well below the national average of 10th grade. Conclusion: A significant percentage of patients at DFHC are at risk for poor health literacy, and therefore poor compliance and worse health outcomes. Fortunately, the PEMs are written at a level lower than that of the national average but are still written at a level too high for patients at DFHC. Virtual Office Visits in Harney County - an assessment of attitudes and access to care Project Date: 3/16/2009 Access to health care is a growing concern in the United States that disproportionately affects those in rural areas already working to overcome barriers in physical access. Technology has the ability to bridge some of these physical gaps and may be particularly effective at increasing access in geographically isolated areas. Virtual office visits – the online interaction between patient and physician – may be one of these technologies. This study was designed to evaluate patient and physician attitudes toward virtual office visits in Harney County and to gather logistical information to assist in the eventual development of a pilot project. A standardized survey was developed and data was collected over a two week period. Physicians and office staff were interviewed and models for virtual office visits in other locations were reviewed. Overwhelmingly, patients and physicians expressed interest in piloting virtual office visits in Harney County and felt that this technology would improve access to health care and consequently would improve health outcomes. Several common concerns were also identified and problem-solving strategies were discussed. At the completion of the study, a document with compiled results of the survey, synthesized data from the interviews, and suggested options for pursuing a pilot project was presented to staff at the High Desert Medical Center. Perceptions of Place, Health, and Illness Among Longtime Tillamook Residents Project Date: 3/16/2009 Cultural competence within health care systems and among providers is an increasingly important issue as public health officials and policy makers look for cost effective means to improve health. Cultural competence of medical professionals within rural American populations is particularly important in efforts to attract health professionals to rural areas, to augment the success of public health interventions, and to improve health outcomes and patient satisfaction. With this project, I added to cultural knowledge that bridges the urban medical community with rural, specifically Tillamook, Oregon, communities. I interviewed six longtime Tillamook residents who have lived in Tillamook for at least 50 years. I asked each of these participants a series of questions designed to elicit their perceptions on diverse topics, including personal history, geographic and cultural identity, occupational health, expectations of health care, experiences of illness and grief, and beliefs about depression. Three important, recurring themes included Tillamook residents’ positive perceptions of rural lifestyle and of Tillamook; their self perceptions as being independent, self-reliant, and stoic; and their shared belief that physicians should be skilled at developing high quality relationships with patients and that rural doctors are more successful at this than are urban doctors. These findings enhance our understanding of rural patients as ones who desire highly individualized health care with respect and support of their cultural values that include hard work, self-reliance and self-healing. End-of-Life Care Decision Making in the Illinois Valley Project Date: 3/16/2009 The importance of end-of-life care can not be understated, it is the last thing we do for our patients. It has been an area of research and systemic improvement for 15 years, but we continue to see limitations in our care, namely short median stays in hospice (17 days in Oregon) and rural/urban discrepancies in percentages of resident deaths that are hospice enrolled (46% in Multnomah County vs. 36% in Josephine County). This project attempts to delineate patients' values in when considering end-of-life (EOL) care in order to examine some the upstream variables that determine how and when we provide EOL care. The design was a qualitative assessment of community members' values in EOL care decision-making through individual semi-structured interviews and anonymous voluntary surveys of community members and primary care providers (PCP). It was found that among patients that have discussed EOL with their doctor, PCP was the most influential person in their decision on EOL, though specialist and family members were also important inputs. A Long Road Ahead: Barriers for the transition to a patient-centered medical home model of care in the rural setting Project Date: 2/9/2009 The “medical home” concept has emerged in recent years as a potential solution to make quality health care more affordable and accessible. It is defined as a patient-centered team effort to provide comprehensive and coordinated care over a sufficient duration of time to foster a strong level of patient-physician understanding and trust. The literature has demonstrated that this model has the ability to improve quality, reduce errors, and increase both patient and physician satisfaction. The team is a fluid network of health care professionals whose composition changes over time to meet the patient’s changing needs, with the primary care physician always operating as the team leader. The patient-centered medical home (PCMH) model also involves payment reform that compensates primary care physicians for productivity that has previously gone undercompensated, all while containing overall health costs. For small practices without pre-existing technologic or staffing infrastructure, the transition to a PCMH identity may by overwhelming or even seemingly insurmountable due to the potential for decreased productivity, financial strain, and personnel shortages. While working in the Tillamook, OR community, I investigated some of the barriers that a particular practice, Bay Ocean Medical, or others like it, might encounter should they opt to acquire that designation. Coming Out of the (Sample) Closet: Pharmaceutical Samples at Dunes Family Health Care, Reedsport, OR Project Date: 2/9/2009 Introduction: Pharmaceutical samples are commonplace in most medical offices in the United States, including Dunes Family Health Care in Reedsport, Oregon. The goal of this study was to assess the current inventory of drug samples at Dunes Family Health Care, and to survey the providers’ attitudes toward the presence of drug samples and industry detailers in the office. Materials and Methods: A comprehensive inventory of all drug samples was performed. The products were then further stratified by cost and therapeutic purpose. Voluntary surveys regarding pharmaceutical samples were distributed to all clinic providers with a license to prescribe medication. Results: There were a total of 2305 individual sample units in the clinic, which comprised 81 distinct drugs. The average retail cost per dose was $3.75 (range $0.25 - $21.00). The most common categories of medications in the office were those for asthma and hypertension, each accounting for 13% of the total number of distinct drugs. Survey results demonstrated a decrease in use of drug samples over the past five years. Lack of patient insurance was the most common reason for dispensing pharmaceutical samples. Most providers believe that drug samples save their patients money. Conclusion: Physician opinion regarding pharmaceutical samples varies among providers at Dunes Family Heath Care. There are numerous complex interactions at work when providing sample medications. The best way to ensure a positive outcome is a close relationship with one’s patients and a thorough knowledge of their medical history and social situation. Inpatient Hospital Resources in Astoria, OR: Development of a Patient Library Project Date: 10/13/2008 Patient education is a critical part of effective healthcare delivery. Although patient education begins with healthcare workers, it must be reinforced by other modalities including pamphlets, books and the internet. This study aided in the completion of a patient library for inpatients at Columbia Memorial Hospital in Astoria, OR. The design was consisted of observation of patient care and exploration of current resources at CMH, meetings with the Stewards, data collection of population demographics and inpatient diagnosis. To aid in its completion, this project consisted of (1) Instructions of how to access WebMD for a novice computer user; (2) Pamphlets for the most common inpatient admissions at Columbia Memorial Hospital; (3) Development of a handout of patient friendly websites. These resources, including the internet, are cost-effective teaching tools. Increasing patient education will hopefully translate to increased compliance, improved patient-physician relationships, and greater patient autonomy. Access and quality of Hospice services for patients and physicians in Josephine County; continual strives towards quality assurance Project Date: 9/8/2008 Rural communities in Oregon are facing the aging population of baby boomers. As such the demand for physicians and Hospice services to deal with end of life care is in high demand. Nationally and within Oregon, rural hospices are faced with additional burdens of large square mileage areas of coverage, increased financial burden due to higher overhead costs and less Medicare reimbursement per patient, and late referrals to care with short lengths of stay. Through analysis of a physician survey about hospice experiences and interactions, interviews conducted with Hospice personnel and patients, and local and statewide annual reports for Lovejoy Hospice located in Grants Pass, OR was analyzed for its ability to address the aforementioned issues. It was found that Lovejoy Hospice through several methods such as attention to provider vs. patient locations, extensive annual fundraising, and finally a physician handbook and positive community presence and patient interaction, has addressed these problems and physician concerns with Hospice referrals and transition to care. However, through physician surveys and Hospice personnel interviews, it was identified that the transition to Hospice care could be smoother and that one are of improvement would be initiating earlier hospice planning so a plan was in place before acute patient decline. Therefore, the final product of this project was development of a patient/physician resource handout and pre-enrollment consult form providing physicians with an in-office way to initiate a conversation about end-of-life and hospice care, and brief patient epidemiology and end-of-life desires for Hospice to have on file in order to facilitate a smoother transition to Hospice care. Management of Chronic Pain in Reedsport, Oregon Project Date: 8/4/2008 It is estimated that between 15% and 30% of the population of the United States suffers from chronic pain. In Reedsport, Oregon, the number individuals in chronic pain are estimated to be higher than the national average because of a higher percentage of: population over 45 years of age, non-hispanic white adults, and population below poverty level. In addition, unique local factors contribute to the number of people in chronic pain, (e.g. occupations requiring manual labor and high risk recreational activities). After seeing a number of chronic pain patients with abuse and diversion of their medications during a five-week medical student rotation, this medical student wondered if anything could have been done differently for these patients. Thorough observation of office policies and procedures, and interactions between physicians and their chronic pain patients at Dunes Family Health Care (DFHC) were documented. A literature search employing OVID Medline and other professional websites was used to compare what was observed in clinic and the existing standard of treatment recommendations. Emphasis was placed on recommendations from the Institute of Clinic Systems Improvement, the American Academy of Family Physicians, and the Oregon Health Plan. On the final day of the rotation, these observations and recommendations were presented to the DFHC physicians. A pamphlet aimed towards eliciting patient expectations during the course of chronic pain treatment was also produced with the intention of distribution to patients at the start of medical therapy. Old Believers of Silverton, Woodburn and Mt. Angel Area Project Date: 8/4/2008 10,000 Russian old believers community presents a significant percent of Marion county and especially Woodburn and Silverton area. Even though a great majority of them speak English well, their cultural specifics sometimes makes providing a health care for them difficult. Some of greatest concerns of health care providers were identified and included: culture and lifestyle of Russian old beliers; their general attitude toward medical care; family role distribution and medical decision making; women health issues, including early marriage and pregnancies as well as birth control; children health and immunizations; and end of life issues. These issues were then investigated and presented. Due to limit of time available for the project, information was collected from limited sources. Preventing Caregiver Burnout in Grants Pass, OR Project Date: 8/4/2008 At any given point, there are 34 million Americans who provide full or part-time care to aging family members or spouses1. Unfortunately, caregiver stress and burnout continues to be an under-recognized and under-addressed phenomenon, despite its association with increased morbidity and mortality in both caregiver and care-recipient. The goal of this project was to identify resources readily available and easily accessible to caregivers in Grants Pass, Oregon. The design included observation of physician interactions with caregivers and their dependents at WellSpring Family Practice and Three Rivers Community Hospital as well as exploration of local, state, and national support resources for caregivers. Finally, the end-product of this project was a pamphlet outlining essential steps for the caregiver and elucidating the most useful and comprehensive resources available. The pamphlet was made to be distributed in the physician’s office and various other health resource offices (e.g. CareSource, assisted-living homes). Management of Patients Abusing Opiate-based Analgesics in Grants Pass: Individual Healthcare Provider Practices, Clinic Guidelines, and Resources and Obstacles in Josephine County Project Date: 6/30/2008 Management of patients abusing prescription opiate-based analgesics is challenging and requires the interplay of many different healthcare providers and community resources. This study identified individual healthcare provider approaches to the management of this population of patients, Grants Pass Clinic policy, and the resources available in and around Josephine County. Information regarding individual healthcare provider practices was obtained via a questionnaire, while resources for and obstacles to the management of this population was gathered through interviews. Healthcare providers generally shared common views and strategies regarding the management of patients abusing prescription narcotics. Discrepancies were found when considering the use of pain contracts and the appropriate time to fire a patient. Grants Pass Clinic had no policy or patient information on the management of patients abusing prescription narcotics aside from the pain contract, so a double-sided handout was created to address the need. Grants Pass has many opportunities for individual drug counseling, less opportunities for group counseling, and nearly no maintenance therapy services (methadone or Suboxone). Possible means to improve access and availability to patients abusing prescription narcotics include increased government funding, reducing healthcare provider prejudice, and increasing the number of healthcare providers trained in Suboxone administration. Exploring the Potential of Art Therapy as Complementary Medicine in the Treatment of Chronic Pain Project Date: 6/30/2008 Chronic pain is a complex health problem and a source of frustration for both doctors and patients. In treating only the physical component of chronic pain, allopathic medicine fails to adequately address the psychosocial, emotional and spiritual components. The purpose of this project was to explore the potential of one modality, art therapy, as complementary medicine in the treatment of chronic pain. While art therapy has been applied in the psychiatric and oncology settings for many years, little research has been conducted on the potential benefits of art therapy as complementary medicine in the treatment of chronic pain. My project included extensive on-line research of websites devoted to art therapy, search of journal articles in Medline, search and identification of art therapy resources in the Lebanon area, sharing my own experiences using art as therapy, and reading The Art Therapy Sourcebook. I proposed further avenues for research on the efficacy of art therapy in treating chronic pain and explained why this could be a valuable form of complementary medicine in a rural setting. Finally, I sought to leave a tangible source of inspiration for patients at the clinic by designing and completing a large painting. Chronic pain is a complex health problem and a source of frustration for both doctors and patients. In treating only the physical component of chronic pain, allopathic medicine fails to adequately address the psychosocial, emotional and spiritual components. The purpose of this project was to explore the potential of one modality, art therapy, as complementary medicine in the treatment of chronic pain. While art therapy has been applied in the psychiatric and oncology settings for many years, little research has been conducted on the potential benefits of art therapy as complementary medicine in the treatment of chronic pain. My project included extensive on-line research of websites devoted to art therapy, search of journal articles in Medline, search and identification of art therapy resources in the Lebanon area, sharing my own experiences using art as therapy, and reading The Art Therapy Sourcebook. I proposed further avenues for research on the efficacy of art therapy in treating chronic pain and explained why this could be a valuable form of complementary medicine in a rural setting. Finally, I sought to leave a tangible source of inspiration for patients at the clinic by designing and completing a large painting. Implementation of a literacy assessment tool: “The Newest Vital Sign” Project Date: 6/30/2008 In recent years there has been increasing emphasis on improving communication between patients and clinicians. There is more awareness now that the old methods of physician teaching are often not working to adequately inform patients. This is for a variety of reasons but this paper focuses on the issue of health literacy as one of the primary factors. Low literacy rates have now been linked to less knowledge of health problems, more hospitalizations, higher health care costs, and poorer health status so obviously it creates a barrier to effective communication. By finding and implementing a quick and easy literacy assessment tool the McClaine Street Clinic and the Community Outreach Clinic in Silverton hope to identify and help those patients with limited literacy. In my study I obtained assessment tool materials, discussed implementation with both offices, and did a small field study to determine the feasibility of administration. Use of email in a rural family practice setting: a strategy to meet increasing demand on limited health care resources in John Day, Oregon. Project Date: 2/11/2008 The challenges created by physician shortages in rural communities require creative solutions that maximize available resources. Previous studies have demonstrated that Internet technology such as email, electronic medication refills, and web consults has the potential to improve efficiency and increase productivity among family practice clinics. It has also been shown that a majority of patients use the Internet and are interested in electronic communication with their physician. This study attempted to determine the number of patients in a family practice clinic in rural John Day, Oregon that have access to the Internet and are receptive to emailing with their doctor. Methods included a survey and informal interview of a convenience sample of patients at the clinic about their use of the Internet and attitude toward using this medium to interact with their doctor. Information about gender, age, and place of residence was also recorded. Fifty-nine percent of patients sampled did not use the Internet and were not interested in any form of Internet technology to communicate with their physician. This attitude was found entirely among elderly patients who cited their inability to navigate the web and lack of understanding of its potential benefits as reasons for not using the Internet. This survey showed that patients in John Day do not have enough interest and fluency in Internet technology to make this form of communication a viable option at this time. A better way to manage Diabetes in Eugene, Oregon: The DWAP Project Date: 10/15/2007 The prevalence of Diabetes Mellitus in the United States has been rapidly increasing in the past seventeen years. The complications of poorly managed diabetic care can be disastrous for patients, their families, and society as a whole. PeaceHealth Medical Group of Eugene, Oregon has instituted a Diabetes Wellness Assessment Program (DWAP) in order to maximize diabetes management and avoid these complications. The DWAP program follows the American Diabetes Association’s guidelines of care, and includes comprehensive visits, modifying behaviors, and data reporting in order to improve care for patients with diabetes. Since its inception three years ago, the DWAP program has shown widespread improvement in the way physicians and clinics manage this chronic and potentially debilitating condition. An analysis of barriers to regular exercise and implementation of a patient handout in Philomath, OR. Project Date: 9/10/2007 Benefits of exercise and increased physical activity are well documented. Despite this, many patients of Philomath Family Medicine (PFM) do not engage in regular exercise. At PFM the barriers preventing patients from engaging in regular exercise were assessed by interviewing multiple physicians within the practice, a local expert, and by patient survey. During observation of physician-patient discussions, physicians often lacked the time to thoroughly explore patients’ reasons for inactivity. A patient handout was created to stimulate self-reflection and provide education and motivation for how to overcome personal barriers. The Use of Herbal and Supplemental Medicine in Coos Bay, Oregon Project Date: 8/6/2007 Many patients have incorporated herbal and supplemental medicines into their health care. There are an unidentified population of patients at the Bay Clinic, who use herbal/supplemental medicine without knowledge of proper usage or the risks. Additionally, there is a general lack of communication between patients and physicians concerning herbal/supplemental medicine usage. This study attempted to define how patients use herbal and supplemental medicine, assess what they know about it, and to facilitate a means to identify supplement users on a daily basis and open a line of conversation between patients and physicians through a brochure. Interviews were conducted with patients of the Bay Clinic who use herbal and supplemental medicine as the main method of investigation. Eighty percent of the patients admitted to supplement usage with the majority using it for long-term health maintenance or chronic health problems. All of the patients felt that supplements were safe and were generally unaware of the possible complications. A pamphlet was created using information gathered from the interviews and literature searches, and it included advice on reading supplement bottle labels, words of caution, interactions and side effects of the more commonly used supplements, and resources for more information. The pamphlets were distributed to the internal medicine faculty at the Bay Clinic and has served as a discussion aid. Barriers to Care in Coos County Project Date: 8/6/2007 Background: 15% of Coos County’s 41,997 inhabitants are on or below the poverty line, with 15% utilizing the Oregon Health Plan (OHP) and 1.5% utilizing cash assistance known as Temporary Assistance for Needy Families (TANF). Forty percent of the North Bend Medical Center pediatric patients have OHP health insurance. Objective: Identify barriers in accessing and maintaining healthcare and public services in Coos County. Methods: Semi-structured telephone interview of parents of pediatrics patients at North Bend Medical Center regarding obstacles to healthcare and public services. Interviews with a county nurse practitioner and case managers of the Department of Human Services (DHS). Literature review for barriers to pediatric health services in rural towns. Results: OHP was praised for its coverage of children, which gave families access to “great doctors.” Parents cited no difficulty getting appointments for their child’s health or for public services. The DHS office was considered well run with “helpful staff.” Cost and transportation are not common obstacles. The forms for TANF/OHP eligibility are considered confusing and are not finished with out the aid of case managers at DHS. Conclusions: Coos County’s public services are providing families below the poverty line with the necessary resources to accessing and maintaining healthcare for pediatric patients. A further investigation is warranted to investigate access to healthcare for children of the “working poor.” The Storm of Users: How can physicians actively participate in identifying and treating addiction without falling into the common pitfalls of either ignoring or contributing to this growing problem? Project Date: 3/19/2007 Substance dependency in this country is continuing to grow at epidemic rates. Some estimates indicate that twenty percent of primary care patients are affected by substance use or dependency, with upwards of fifty percent of emergency room visits being related to drugs or alcohol. The overwhelmingness of this problem has left our healthcare system fractured without clear roles for providers. This project attempted to explain how physicians could actively participate in identifying/treating addiction without falling into the common pitfalls of either ignoring the problem or contributing to it. Data was collected through informal interviews of key individuals with some role in substance use/dependency, recover, treatment, prevention, or enforcement. Collaborating data was collected from the Oregon Department of Human Services, National Institute on Alcohol And Alcoholism (NIAAA), and the National Institute on Drug Abuse (NIDA). Results found that the enormity of the problem is paralyzing. The consensus of individuals interviewed was the substance dependency is a growing problem with no signs of slowing in the future. At present due to the lack of a uniform approach, appropriate training, lack of time and resources, physicians are often tempted to ignore the problem or even add to it by careless prescription practices. Proper identification of the problem, education, and treatment with whatever means available (inpatient, outpatient, 12-step, individual, group) is key to future efforts. 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. Telecommunications Technology and Medicine in Burns, Oregon Project Date: 1/1/2007 Telemedicine uses telecommunications technology for medical diagnosis, follow up, and therapeutic purposes when distance separates the patient from their doctor. It is ideal, in concept, for patients who live in rural ares, and are forced to travel long distances to see specialists typically centered in urban areas. Studies show that setting up this remote interaction is possible, but there is little evidence that is is an efficient and cost effective means of delivering care. High Desert Medical Center in Burns, Oregon was given equipment through various grants to set up telemedicine services, but little has been done in terms of implementing it into a useable practice. An analysis of the benefits of and barriers to creating a lasting operational telemedicine service was undertaken to help guide future efforts. A survey of patient opinion was performed, and a newsletter article was drafted to educate the public about telemedicine. Perspectives on end of life preparedness and POLST implementation by providers in Reedsport, Oregon. Project Date: 1/1/2007 End of life planning is an emotionally charged topic of discussion for medical personnel, patients, and families. Throughout the country, the use of heroic and expensive treatment for those with terminal conditions is the subject of debate by medical personnel as well as ethicists. End of life practices vary by hospital and certainly by demographics. This project seeks to explore the attitudes and practices of seven medical practitioners in a family health clinic in a coastal community in Oregon. The unique environment that is embodied in this town is similar to other small rural communities across the country. Reedsport has a critical access hospital that contains 22 acute care beds with accommodations for two ICU beds. It also has an extended care facility associated with the hospital. Its ER is staffed primarily by local family doctors. The family practice clinic serving this health district is located immediately adjacent to the hospital. This presents a unique opportunity to evaluate the practice and implementation of end of life measures in different medical settings by the same medical practitioners. Many if not all of the patients who are admitted to the local hospital by the ER physicians are also the patients of these same practitioners of community based medicine. Attitudes toward end of life issues were sampled by personal interview and completion of a small survey. Strategies are discussed for the increased implementation of POLST forms in the practices of these providers and in their community. Increasing Access to Health Care in Hood River County: Mobile Health Unit Project Date: 10/16/2006 Millions of Americans do not have access to health care especially in rural communities. Hood River County has a population of 19,691 with the following characteristics 18.1% are uninsured, 14% live below the poverty level, 15.5% on disability between ages 16-64, 36.2% of children on free or reduced lunch, and 27.2% are Hispanic. The barriers preventing people within Hood River County from accessing health care include transportation, distance to care, uninsured, underinsured, immigration status, language barriers, and lack of knowledge on how to access health care. Providence Hood River Memorial Hospital (PHRMH) serves Hood River County and is located in Hood River. PHRMH identified lack of access to health care as a major problem within the county and created Mission in Motion – Mobile Health Unit (MHU) to bring access to health care to the people of Hood River County. After interviewing employees and observing the MHU in action I learned about the MHU and how it was started. MHU is a 35-foot RV purchased from eBay and refurbished into a mobile health clinic that services the small communities of Hood River County. It is staffed by physician or physician assistant, medical assistant, and driver. The mission of the MHU is to provide first time medical visits to patients that do not have access to health care or do not have a primary medical home and then set them up with a permanent medical home. In the first weeks of service 32 patients were seen with the top three reasons being blood pressure checks, high blood glucose, and cold/sinus infections. The MHU is still in its early phases and there are some concerns regarding potential for abuse as a primary care center. Patients have been appreciative of the services. The community of Providence Hood River health system should be applauded for their efforts to increase access to health care among the population of Hood River County. Effectiveness of hypertension management in Astoria, OR. Project Date: 10/16/2006 Hypertension (HTN) incidence and prevalence continues to increase across the country, with a higher disease burden found in some rural areas. In fact, it was the most frequent diagnosis recorded for all routine health checks (4.1%) in the US, and in a small Family Practice clinic in Astoria, OR, HTN was the reason for 6.1% of visits per day. However, recent studies show only 20-30% of those with HTN have optimally controlled blood pressures (BP). I researched current recommendations for successful management of HTN in the literature, and used this information to investigate the effectiveness of HTN management in this small Family Practice clinic in Astoria, OR. A flowsheet was created to focus on these guidelines and a chart review of 35 patients was done using this tool. Data was collected, including weight, BMI, BP, risk factors/secondary causes, PE and labs done, medications, and expected follow-up. Results showed that these two Family Practitioners did an outstanding job of overall BP management, with almost ¾ of their patients at or below their goal BP, and timely lab follow-up. Areas of improvement include stricter use of recommended medications for specific co-morbidities, consistently including fundoscopic exam as part of the PE, and ordering EKGs. This information can be used as a background for future HTN management in this clinic, with utilization of the flowsheet to aide in the improvements discussed. Chronic Pain Management and Prominent Issues Among Rural Health Professionals in Baker City, OR. Project Date: 9/11/2006 Chronic pain management continues to be a major issue in the health care arena. Particularly in rural communities where access to multidisciplinary pain centers is acutely limited, the issue of proper care and treatment of pain remains a prominent concern for health professionals. The primary objective of this project was to understand the approach to pain management in a rural family practice clinic in Baker City, Oregon and identify available community resources that aid in the treatment of patients with chronic pain. Informal discussions with physicians, nurses, physical therapists, and pharmacists helped in elucidating current attitudes of chronic pain management and the challenges associated with its adequate treatment. Analysis of patient records allowed closer study of prevalent diagnosis and the medications used for pain treatment. The overall conclusion of this student is that there is an ever growing need to continually evaluate and discuss challenges in pain management and assess the adequacy of current protocol. The adoption and consistent use of pain contracts between patients and physicians is one desirable step towards the better monitoring, and therefore, better care of patients in pain. Educating Parents in Coos County, Oregon: Development of a Postpartum Class at Bay Area Hospital Project Date: 9/11/2006 Many parents of newborn infants are not receiving the information that they desire from their health care professionals. Well child care visits with the pediatrician usually occur at birth, 2 weeks, 2 months, and so forth. During these visits, anticipatory guidance is often limited by the time and preference of the physician. Mothers were indicating a desire for more information and pediatricians were confirming an increased number of phone calls and office visits regarding these same issues. In order to identify the topics of concern as well as propose an educational solution, investigatory interviews were conducted with 10 mothers, 3 pediatricians, and 4 maternal education staff members. Interview results confirmed that parents expressed to know more on the following topics: increased crying, a variety of baby health issues, mother's health issues, sibling adjustment, returning to work, feeding issues with returning to work, time management, and safety. Using the results of these interviews, as well as the published guidelines on anticipatory guidance, a class was developed entitled Postpartum 101: Practical Tips For Parents of 2-8 Week Old Infants. The hour long class consists of a powerpoint presentation, discussion questions, hands-on activities, and associated handout. The class is scheduled to be taught regularly by a local pediatrician and nurse under the auspices of the maternal education program at Bay Area Hospital. The metabolic syndrome in Coos County, Or: Causative factors, and issues for treatment. Project Date: 5/1/2006 The Metabolic Syndrome, which is defined by a combined set of cardiovascular risk factors, has a rising prevalence in the U.S. in recent years. Certain communities, including Coos County, OR have even higher rates than that of the general population. This study aimed at determining factors which increase the prevalence of the metabolic syndrome in Coos County, and looked at patient education as a means for aiding the problem. The study was carried out by interviewing physicians and patients, as well as consulting the county health department to help determine causative factors. Using this information, an education handout was developed and used during short teaching sessions with a representative sample of patients. Finally, patients were interviewed regarding their thoughts as to whether this was helpful for their overall knowledge of the disease. Conclusions taken from the study were that, although many factors contribute, patient education is one modifiable aspect that should be a focus for improving rates of the metabolic syndrome. While the teaching sessions used in the study may not have been time-efficient, they were met with positive feedback, and a more time efficient strategy may be the most ideal means. Tobacco Cessation Counseling: Are We Wasting Our Breath? Project Date: 5/1/2006 Tobacco use is a major public health concern and affects 21% of all Oregonians and 29% of residents of Douglas County, a rural area in Southwestern Oregon that includes the town of Reedsport (population 4500). It is the leading cause of premature death and disability in the state, and the medical and economic consequences of its use are well-documented and well-publicized. The purposes of this project were to research current evidence-based literature and clinical practice guidelines, and compare the current recommendations to individual practices at Dunes Family Health Care (DFHC) clinic, the major health-care provider for the town of Reedsport. This was done in order to identify areas for improvement with the intent of potentially improving patient quit rates. A questionnaire detailing their current practices regarding tobacco cessation counseling was distributed to all providers at the clinic. Results demonstrated that physicians at DFHC are consistently asking their patients about tobacco use and advising them to quit. However, similar to providers around the country, they are often not assisting patients in the quitting process by recommending over-the-counter nicotine replacement therapy, prescribing approved cessation pharmacotherapy, or referring patients to tobacco quit lines, all methods that have been shown to potentially double patient quit rates. In a presentation to providers at the clinic, each of their cited barriers to effective and comprehensive tobacco cessation counseling were addressed and strategies for improvement were given. Ideally, this project will have empowered physicians to provide their patients with the tools necessary to optimize their chances for a successful quit attempt. Length of patient enrollment on Blue Mountain Hospice, The Physicians who refer patients and suggeted strategies to reduce late referrals Project Date: 3/20/2006 Blue Mountain Hospice (BMH) opened in August 2005. As with most hospices, one of its main concerns is that a significant proportion of its patients are enrolled for only a matter of a few days. The concern is that as a result, many of these patients and their families may not have time to fully benefit from the services hospice has to offer. The goals of this project were to 1) further the degree of mutual understanding between the physicians of Grant County referring patients to BMH and the staff of BMH; and, 2) provide recommendations and resources to both the physicians and BMH on possible strategies which may help to reduce late referrals. To accomplish these goals, the seven Grant County physicians were surveyed on hospice referral history, training and attitudes towards hospice, barriers to timely referral and interest in hospice related continuing education. Files of patients referred to BMH were then reviewed to characterize the population referred. Results indicated that referring physicians generally believe they are well trained in hospice, express positive attitudes towards hospice and are moderately interested in continuing education. Of the 15 patients enrolled with BMH to-date who ultimately either died on hospice (12) or were discharged (3), the median length of enrollment was 6.5 days and two patients were enrolled for only one day. Recognizing that certainly not all of the late referrals could have reasonably been avoided, recommendations and associated resources are provided to both BMH and the referring physicians with the intent that the proportion of late referrals can, over time, be reduced and more of the patients and their families can fully benefit from the unique services offered by hospice. Transforming Rural Primary Care: Electronic Medical Records (EMR) in Coos Bay, Oregon Project Date: 2/13/2006 EMR has advantages over paper-only charting systems in accuracy, speed, portability, and information retrieval and sharing. Yet it is costly to initiate and introduces its own set of possibilities for error, to include digital security breach and computer “crash.” In any case, EMR is not widely used in the United States, with estimates ranging from 7-33% of primary care clinicians. However, it is being used in the continuity clinics of 46% of Family Practice residency programs. The Bay Clinic Internal Medicine practice in rural Coos Bay, Oregon, is transitioning to partial EMR from a paper-only system. It plans to uniformly implement EMR within one to three years, and interface with the pending internet-based EMR of Bay Area Hospital. Bay Clinic is one of the sites for a required Rural Medicine clerkship for third-year medical students from Oregon Health & Science University (OHSU), in Portland. Study observations are made using the “PRAXIS Version 3.2” EMR by Infor-Med Medical Information Systems, Inc., between February 15 and March 15, 2006. The medical student used the EMR for every patient encounter, primarily to chart. One internist used the EMR for roughly 50% of his patient encounters on a given day, primarily to chart. A second internist used the EMR for every patient encounter: to chart, set clinical reminders, e-mail staff, write clinic letters, and print prescriptions and patient handouts. Both internists increased their average number of patients evaluated per day by about 25% (self-report), as compared to their practices when using paper only. We do not believe that using computers in the exam room diminished provider-patient interaction. Future studies may focus on the quality of this interaction, and of charting in general, as influenced by EMR. We anticipate that using EMR at this rural site will continue to benefit rotating medical students in learning practice guidelines and workflow efficiency. Care of hypertensive patients in John Day, Oregon: Creation of a clinical reminder checklist. Project Date: 2/13/2006 Hypertension is a medical problem seen by every physician, regardless of his or her specific practice or the type of community they practice in. For physicians in rural communities, it is a diagnosis seen daily. The identification and treatment of patients with hypertension is lengthy, somewhat confusing, and frequently changing. In 2003, the National Heart, Lung and Blood Institute (JNC7) created a new treatment algorithm for hypertensive patients. This study attempted to determine whether or not two physicians in a rural family practice clinic in John Day, Oregon were appropriately caring for their patients with hypertension according to the guidelines set forth by the JNC7. The design was a random selection of 20 patients already diagnosed with hypertension, followed by a chart review of these patients. The chart review identified specific areas the physicians were doing well with and a few that they were lacking in. The results of the chart review prompted discussion of the best way to be consistent and complete with the care of every hypertensive patient. It was decided that a checklist with reminders for specific aspects of the physical exam, laboratory tests, lifestyle modifications, and medication review would be created. Two checklists were created including one for the initial diagnosis of hypertension and one for those already diagnosed. These checklists will be placed in the charts of all pertinent patients. It is expected that these checklists will make it easier for the staff and physicians to provide consistent care of their patients with hypertension according to the guidelines set forth in JNC 7. Examining Barriers to Physician Referrals to Hospice Care in Josephine County Project Date: 2/13/2006 The goal of hospice care is to provide palliative care, symptom control, and emotional, spiritual, and social support for both patients and their families. Hospice services are meant to provide quality of life during the dying process. Lovejoy Hospice receives approximately 50% of referrals from area physicians and approximately 45% directly from families. These percentages either reflect a high public awareness of hospice services or that there are barriers for physicians when it comes to offering hospice as an option. Therefore, a survey was designed to help identify barriers in the physician community. The survey includes questions about physician and hospice interactions, the difficulties of discussing end-of-life care, the tools physicians would find helpful in an end-of-life discussion, and the awareness of the range of diseases and age groups that hospice can serve. The responses will be analyzed and, hopefully, barriers identified. With this data, strategies can be developed to aid physicians in overcoming barriers to offering patients hospice care as an end-of-life option. The desire to help physicians overcome barriers comes from the ultimate goal of ensuring that no patient goes without hospice care because the option was not presented to them. Diabetes management in John Day, Oregon: a summary of objective measures of diabetes care and the impact of an appointment reminder system on HbA1c testing frequency Project Date: 1/2/2006 BACKGROUND: The prevalence of type II diabetes is growing nationwide, a trend that includes both urban and rural areas. Intensive diabetes management is a cooperative process between patients and their health care providers: providers have an opportunity to help their patients intervene in an otherwise progressive disease by prescribing medications to improve glycemic control, blood pressure, and cholesterol, screening for complications, and encouraging appropriate lifestyle modifications. Rural settings have the unique challenge of meeting the needs of their patients and complying with complex documentation requirements without the benefits of extra staff or record systems dedicated to diabetes care. OBJECTIVE: The goals of this project were to summarize current objective measures of diabetes care in Dr. Holland’s practice in John Day, OR, assess the management of diabetes before and after the implementation of an appointment reminder system started in July 2003, and create a record system that the nursing staff can use to help improve the documentation of diabetes care. METHODS: A chart review of all patients with diabetes in Dr. Holland’s practice was performed. RESULTS: The chart review identified an average HbA1c of 7.5, blood pressure of 140/74, total cholesterol of 161, triglycerides of 169, HDL of 35, and LDL of 91. The implementation of the appointment reminder system on July 2003 improved the frequency of HbA1c testing. Finally, a database was generated to aid in identifying patients due for an appointment and in documenting vitals, exam findings, and lab values. CONCLUSIONS: Objective measures of diabetes control in Dr. Holland’s practice have been described, and strengths and areas for improvement were identified. Dr. Holland and the nursing staff plan to use the database generated as part of this chart review to aid in reminding patients about their appointments and in documenting diabetes care. Where did you get that idea? Developing an Integrated Strategy for Patient Information Handouts Project Date: 1/2/2006 The brief time allotted to office visits limits patient education on acute primary care issues. Many practitioners rely upon written information they can give to their patients to follow at home. This study attempted to define a strategy for creating and refining patient education handouts in a Florence, Oregon family medicine clinic. While there were plenty of patient handout materials already existing in the clinic, these were often out-dated or otherwise inappropriate for use. The design was to work with physicians to identify areas where handouts were needed, articulate core concepts that physicians wished addressed, elicit patient feedback on handout materials and create handouts to satisfy these specific goals. Finally, further thoughts on extending the project were considered. Bariatric Surgery in Reedsport, OR Project Date: 10/17/2005 Obesity is a growing problem in the United States and the popularity of bariatric surgery continues to increase. This research project was designed to address many of the issues that are specific to offering bariatric surgery in a rural hospital. A literature review was conducted to determine how morbidity and mortality rates are affected by bariatric surgery performed in a rural setting. Possible reasons for these differences were discussed. Patient demographic factors associated with perioperative complications were identified in order to be able to screen for relatively low-risk patients. The most common complications were discussed, as well as projected rates for these complications. Finally, the plans for the new bariatric program at Lower Umpqua Hospital in Reedsport, Oregon were outlined and potential benefits and drawbacks of the program were discussed. Reach Out and Read: the first steps toward establishing a local program. Project Date: 10/17/2005 Discussions with Kindergarten teachers and reading coaches at several schools in Jefferson County, supported by the DIBELS* standardized literacy test scores for this year, revealed a high percentage of children who are at risk for not meeting benchmark goals in literacy without significant intervention. A growing body of evidence suggests that physicians can play a role in promoting literacy by adopting the strategies presented through a Reach Out and Read program (ROR). Providers give a brand new book to children between the ages of 6 months – 5 years at their well child exam, accompanied by age-appropriate advice to parents on how to effectively read aloud to their children. Retrospective and prospective studies report increased attitudes and frequency of reading to children, as well as higher scores on standardized literacy assessment tests when compared with children not exposed to ROR. The initial steps of establishing an ROR program in Madras were undertaken during this project: gathering local and demographic information to evaluate the need for this program, estimating an annual budget, and presenting the idea to Madras Medical Group, with the goal of attaining a group consensus to continue the steps toward completion of this project. Future steps include identifying and applying for long term funding, generating community support, outlining a plan for creating a “literacy-rich” environment in the office, and finally, submitting the online application to the national ROR center. *DIBELS: Dynamic Indicators of Basic Early Literacy Skills A Chronic Pain Survey: Defining chronic pain, its prevalence, and its severity Project Date: 10/17/2005 Chronic pain is an intrinsically subjective disease. There are no objective methods to measure it. Chronic pain is a disease process that involves psychosocial as much as physical pathophysiology, if not more so. Moreover, there is little consensus among the different specialties and organizations in medicine on the definition, assessment, and management of chronic pain. Because of these, the prevalence rates of chronic pain range from 10 to 55%. A larger number compared to the 10 to 15% of the general population that seeks care for chronic pain, a disparity that is worth investigating. The available studies on large populations vastly out-number those on rural communities. Originally, this project was to analyze the appropriateness of chronic pain treatment in this community as compared to standard guidelines. However, with lack of widely accepted guidelines and little epidemiological data to compare, this analysis was difficult to pursue with the allotted time. The project focus shifted to addressing the prevalence, associated factors, and description of chronic pain in the “rural” community of Burns, Oregon. To accomplish this task, a patient survey was devised that was largely based on two prior descriptive studies on chronic pain in rural communities. The definition of chronic pain used in the survey is an adaptation on the definition by the International Association on the Study of Pain. To describe the more “physical” component of the pain, the survey asks to describe the pain’s location, sensation, intensity, perceived cause, duration, and frequency. To describe a more “psychosocial” aspect of the pain, the survey asks to answer questions from the Quality of Life Scale. Though there was inadequate time, the patient survey is ready and available for implementation. From this potential pool of data, certain outcomes can be ascertained, such as: the validity of this study’s definition of chronic pain and the appropriateness of using current guidelines in the assessment and treatment of chronic pain, including the use of opioid analgesics. Finally, the current chronic pain practice of rural physicians can be surveyed to compare to these guidelines. RESUSCITATION STATUS IN A RURAL HOSPICE Predictors of status & ease of identifying patient preferences in emergent situations Project Date: 9/12/2005 Hospice is a growing resource in American health care that is being increasingly utilized by greater proportions of the population. In order to receive full hospice benefits, a terminal diagnosis with less than six months of expected life is required. Yet, a DNR status is not mandatory for patients who accept hospice benefits. This study attempted to identify patient characteristics that may make a hospice client more or less likely to choose a specific resuscitation status. Methodology included a chart review of 237 patients of Heart n’ Home Hospice and Palliative Care, in Fruitland, Idaho. This hospice first opened in April, 2004. The files surveyed represent all clients of this business thus far. Specific patient characteristics including resuscitation status, age, sex, hospice diagnosis and religious preference were analyzed. Additionally, impromptu hospice employee interviews provided further data concerning project limitations as well as helped to identify an area of need for which this project could serve a purpose. Though unintended during original inception, this project prompted standardization of resuscitation status within the hospice files. Therefore, the final outcome of this project is a standardized system for which emergency inquiries into a particular patient’s resuscitation status could be quickly answered. Underutilization of Hospice Services in the Treasure Valley Area: Are we referring patient too late? Project Date: 8/8/2005 OBJECTIVES: To assess utilization of hospice services in the Treasure Valley area and determine if these services are adequately being used. To determine the views and attitudes of family members and hospice care providers regarding timing of referral. SETTING: Treasure Valley including Ontario, OR, Fruitland ID, Payette ID and neighboring towns. DESIGN: Retrospective analysis of hospice patient charts and Family Evaluation of Hospice Care (FEHC) records from 2004 and 2005. In addition, hospice care providers were surveyed about the timing of referral and usefulness of services offered. PARTICIPANTS: Deceased patients at Heart’N Home Hospice and their surviving family members. Hospice staff including physicians, nurses, counselors, social workers, chaplains, home health aides, and volunteers. MEASUREMENTS: Length of time patients received hospice care, family’s opinion regarding timing of referral (too early, at about the right time, too late) and hospice providers’ perceived average length of stay on hospice and perceived optimum length of stay. RESULTS: Chart review of 126 deceased patients revealed a mean length of stay of approximately 3 weeks. 40 families completed the Family Evaluation of Hospice Care and up to 20% thought that the patient was referred too late and that lack of information was the most common reason. 80% thought that referral was made at the right time. The majority of hospice care providers who responded to the survey believe that the optimum length of stay is 6 month. In addition, most thought that patients stayed on average between 2 and 4 month on hospice. CONCLUSION: The results indicate that in the Treasure Valley area, many family members and hospice care providers feel that terminally ill patients are referred too late and that they could receive greater benefits from longer stays on hospice. The actual length of stay is consistent with that of hospice patients nationally which shows that we are in fact patients are admitted late in the process of end-of-life care. Future effort should focus on patient’s opinion of referral timing and level of awareness of referring physicians regarding prognosis and eligibility characteristics. Hopefully, this could lead to improvements in referral and admission practices. Diabetes Management in Reedsport, Oregon, Is It Under Control? Project Date: 8/8/2005 Rural communities such as Reedsport, Oregon lack the majority of specialists that are present in urban communities. Because of this, most chronic diseases are cared for solely by the family physician. This project addresses the chronic care of diabetes in the Reedsport. This is done through chart reviews and a questionnaire of the physicians at the Dunes Family Health Care Clinic. It addresses the question of how diabetes is currently being managed in Reedsport, Oregon and suggests areas of improvement for increased quality of care in diabetic management. 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. Dual Relationships in a Rural Community Project Date: 4/25/2005 Dual relationships are a complex and sensitive issue, as they commingle two of the most cardinal aspects of life: Health, and loved ones. The literature describes dual relationships as personal relations, familiar or social, with a patient outside of the office. Historically, medical associations' ethical guidelines recommend against this. Yet there is a paucity of research considering whether this is practical, or even opportune, in small communities. Moreover, short and long-term data on the effects of dual relationships is likewise lacking. This study utilized key informant interviews with 10 physicians and 10 patients in Tillamook OR, in order to assess the prevalence and perception of dual relationships in a rural environment. The hope is to gauge whether these relationships are interpreted as beneficial or detrimental, and to assess the need for future education or intervention. A Suggested Protocol for the Management of Recurrent Refractory Migraines in a Rural Setting Project Date: 4/25/2005 Chronic Migraine patients frequently visit physicians (via the clinic or the emergency department) seeking parenteral treatment for severe acute pain. The workload placed on doctors due to this illness – combined with questions surrounding the administration of recurrent narcotics – causes controversy and friction among providers regarding the optimal treatment of these patients. The scope of this clinical issue in the town of Florence, Oregon, is investigated via discussion with clinicians and chart review of one physician’s census of chronic migraine patients. Algorithms based on available evidence are suggested for the management of chronic severe migraineurs in order to a) reduce the number of visits to the clinic and emergency department for acute parenteral treatment; and b) offer effective alternatives to IM narcotics when patients do come to a provider for said treatment. Perceived Availability of Physicians To Patients in the Clinical Setting Project Date: 10/18/2004 Access to medical care is often the main barrier to health in a rural community. While access can take on many different meanings for a community, I chose to focus on the perceived availability of physicians to patients in the clinical setting. I observed an independent Internal Medicine practice of 4 physicians and 2 nurse practitioners serving roughly 12,000 patients in a rural area. Over a five-week period, I observed office staff and physician perceptions that patients have many unrealistic expectations for the logistic aspects of their health care. I listened to patients’ questions and expectations regarding their care by the facility. Unnecessary phone calls and incomplete follow-up were two main complaints by office staff, while not being able to talk to a person on the phone and high cost of medications were consistent problems noted by patients. This informal research resulted in the formation of an educational handout to patients to improve their expectations of the logistics of their medical care. By improving patient knowledge of appropriate interactions with the office staff, it is hoped that there will be a decrease in unnecessary phone call volume, to ultimately improve access to the clinic for urgent concerns. The Road To Recovery: transportation for radiation oncology patients in Lincoln County Project Date: 8/9/2004 Traveling daily to radiation oncology centers for therapy is a roadblock in the treatment of some cancer patients from Lincoln County. A group of providers is in the process of making reliable and inexpensive transportation available to these patients. In this attempt, current information on radiation patients and where and how they receive treatment was needed in order to secure funding and garner support for this program. For this project, the necessary state and county cancer data was obtained from the Oregon State Cancer Registry and statistics and information were obtained from the Samaritan Regional Cancer Center (SRCC) regarding Lincoln County radiation patients as well as physician referral data. This information reveals the number of patients and the likely demand for transportation. It also shows that some patients referred for therapy are not receiving the treatment they need at SRCC. It is hoped that providing this information will aid in the process of securing reliable transportation for future radiation oncology patients from Lincoln County. Investigate the Use of Unconventional Therapy in Scappoose and Portland Project Date: 7/5/2004 Unconventional therapy has become popular in the United States. However, the role of cultural beliefs and population size in unconventional medicine use is not known. This study examines the prevalence of and the reasons that underlie unconventional medicine use in two culturally distinct populations in Oregon: the predominately Caucasian population of Scappoose and the Chinese American community of Portland. A survey was designed and was conducted at the Scappoose and Portland health service centers. Among the 14 Caucasian subjects interviewed in Scappoose, 57% reported using unconventional medicine at least once in their life. All of the 16 Chinese American subjects interviewed in Portland have used unconventional medicine. Whether in Scappoose or Portland, the respondents who had tried unconventional medicine used it for chronic medical conditions such as pain and allergies and consulted medical doctors for serious medical conditions including hypertension and renal failure. Furthermore, only 25% of the Portland respondents who used unconventional therapy informed their medical doctors compared to 75% in Scappoose. These results show that over half of the subjects in Scappoose and Portland have used unconventional medicine. However, the subjects in Scappoose are more likely to communicate their use to their medical doctors than do the subjects in Portland. This pattern of use elucidates the phenomenal prevalence of unconventional therapy and suggests that medical doctors should specifically inquire about the use of unconventional therapy when treating patients with different cultural beliefs. Anticipating Longitudinal Growth Project Date: 2/11/2002 This paper encompasses 3 related projects: first, to assess patient satisfaction with the process of establishing care with a PCP at Peace Harbor's Health Associates clinic in Florence, OR; second, to assess local FNP's perceptions of their professional relationships with their Physician colleagues & to describe some current literature on the topic; third, to assess the attitudes of employees of Health Associates about the quality of care delivered by Mid-levels as compared to Physicians. Such data could prove useful in planning for Peace Harbor's expansion. Three distinct surveys facilitated these goals. On average, new patients consider a (5) day wait "reasonable," but a 23-24 day wait "expected." In light of this, 44% of incoming patients had to wait "longer than expected." 83% of new patients feel the most important quality in selecting a specific PCP is his/her special interest in their disease, about 67% were assigned to their first-choice PCP, & 94% of incoming patients feel provider continuity is more important than not. The current FNP's feel their practice is an admixture of "collaborative" & "parallel" models. Finally, staff & nursing cohorts have overwhelming confidence in Physicians to provide superior primary care over Mid-levels (contrary to results of a randomized trial used as the survey's "answer key"), the Mid-level cohort holds false beliefs about their ability to provide better care than Physicians, & Physicians demonstrate uncertainty about the matter. Back to subject search page or search by preceptor site