RCHC Community Project Abstracts

Back to subject search page or search by preceptor site Chronic Pain Management Protocol: for utilization by primary care providers in Lebanon, OR Project Date: 10/12/2009 Chronic pain is a growing problem in healthcare today. It is unlike many other medical problems that primary care physicians are presented with throughout their clinic day. Chronic pain has many different components and is sometimes referred to as a “biopsychosocial” problem potentially including aspects like trauma, anatomical abnormalities, psychosocial influences and many others. Interdisciplinary approaches to managing pain have been proven to be effective at reducing pain and at decreasing narcotic dependence. Involving multiple modes of support addresses the complexity of people’s pain, and gives many different ways to make lifestyle modifications to help patients better understand how to manage their pain. In order to address the issue of a family medicine provider as a manager of chronic pain, I decided to help the Lebanon, OR family practice with implementing a protocol for evaluation of chronic pain. My goals included increasing access of protocol forms by facilitating incorporation of them into the electronic medical record. I also put together a patient handout that included simple ideas for an interdisciplinary approach to chronic pain management as well as more specific local resources. Fibromyalgia—More than a Pain in the Neck? Dealing with the Diagnosis at the Klamath Family Practice Clinic Project Date: 10/12/2009 Fibromyalgia is a challenging condition affecting 3-5% of the world’s population, and is characterized by a classic triad of chronic diffuse pain, fatigue, and sleep disturbances. Many providers feel somewhat uncomfortable with fibromyalgia, and primary care physicians, especially those in rural areas, are often those who deal most frequently with the diagnosis. It is important that such providers have increasing familiarity with the condition. This community project, therefore, attempted to determine how comfortable providers at the Klamath Family Practice were with the diagnosis of fibromyalgia and to provide them with educational materials regarding the condition. A survey and educational materials were given to the medical providers to achieve this aim. While most of the providers felt familiar with the etiology and treatment options for the disease, some retained discomfort with the management of the disorder. All had suggestions to improve clinical interactions with fibromyalgia patients, relating primarily to increasing patient education regarding the patient role in treatment. The providers found the supplied educational materials informative and comprehensive, and retained them for additional reference. 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 for Chronic Pain Management at a Mixed Rural/Urban Adult Primary Care Practice: Project Date: 9/7/2009 Following passage of the Oregon Medical Marijuana Act in 1998, medical marijuana has been available to Oregonians with severe pain with the endorsement of their physicians. However, this is a controversial subject involving debates of medical marijuana’s legality and effectiveness for treating chronic pain. While scientific evidence supporting an analgesic benefit of medical marijuana has started to materialize, legal conflict between federal and state statues remains. Complicating this is the unique nature of medical marijuana. It is patient-directed therapy that has standard preparation and consequently, diminished ability to determine dose received. These factors have made it hard for physicians to equate treatment with benefit. While working with Dr. John Allcott at Applegate Medical Associates, a primary care clinic with offices in Veneta and Eugene, OR, a 3 component strategy was derived to monitor the effectiveness of therapy for medical marijuana patients. The components are: 1) determining the level of patient disability through evaluation of patient ability to achieve patient-directed goals addressing social, emotional and physical parameters. 2) Educating patients about possible benefits of medical marijuana, potential adverse reactions, and risks of use. 3) Reviewing patient progress with data obtained from standardized instruments (the PHQ-9 depression screening questionnaire for example) and patient ability to achieve individual goals. The final result was a proposed set of questions to be entered into the EMR and utilized by the clinic staff for medical marijuana patients. Optimizing Care of Chronic Pain Patients in a Rural Primary Care Clinic Project Date: 8/3/2009 Treatment of chronic pain can present one of the most challenging scenarios in medicine – both for clinicians and patients alike. Managing constant prescription refill requests and sometimes frustrated patients can be taxing on clinic staff and providers, while communicating the subjective experience of pain can be emotional for patients whose pain may often go untreated or under-treated due to historical sensitivity about prescribing narcotic medications. Further complicating this delicate relationship between patient and clinic is the increasing prevalence of prescription drug diversion and abuse, particularly among American youth. This project investigated current trends in the management of chronic pain at the clinic and community level, gathering information from medical literature, local clinic staff, surveys of chronic pain patients, and interviews with key community role players. A summary of recommendations was developed to assist local providers in optimizing the care they provide to patients with chronic pain. 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. Helping Chronic Pain Patients Improve their Pain and Functioning Project Date: 3/16/2009 Chronic pain is frustrating for patients and physicians alike. It is costly to society in terms of lost productivity and high use of health care resources. Medications are one component of managing pain, but they are most effective when combined with exercise, relaxation, nutrition, and counseling. Like patients with other chronic diseases, those with chronic pain must move from being passive recipients of care to informed, active participants if they are to improve their functioning and quality of life. This project consisted of designing a group visit with an educational didactic session followed by brief individual visits using measurement tools and a standardized progress note to set and evaluate goals, progress, and effectiveness of treatment plans for OHP patients in Silverton, OR. While this project is an attempt to implement a chronic care model with limited resources of a small practice, patients could certainly benefit from a counselor specializing in cognitive behavioral therapy. 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. A Brief Sojourn in the Land of Chronic Pain Medication, as experienced at Scappoose Family Medicine Project Date: 8/4/2008 A recent article in the New York Times detailed the increasing use of methadone for chronic pain in the primary care setting. Often considered by the public as a drug for drug addicts, it is an opioid similar to the prototypical opioid morphine. However, methadone has substantially different pharmacokinetics, and these properties may make the drug dangerous to certain patients. Still, the increase in methadone use continues, likely due to its lower cost relative to other extended-release opioid formulations. Does this pose problems for primary care patients with chronic pain and public benefits such as CareOregon? Does it pose problems for providers who are unaccustomed to or uncomfortable with methadone's pharmacokinetics? Though this short study cannot answer these questions definitively, by considering the patients of OHSU Family Medicine Scappoose, we can learn about chronic pain medications and their use. We also can glean some providers' opinions regarding the prescription of methadone, and the restrictions that they face due to many patients having public benefits. Finally, we may remind ourselves as clinicians that hidden dangers lurk for patients starting methadone, or for those converting to methadone from another opioid. Can Astoria Support a Physiatrist? Project Date: 6/30/2008 Rural communities are disproportionately affected by disabling conditions and chronic diseases. Labor-intensive occupations, older demographics and shortages of medical services contribute to faster progression of disease in rural settings. To address these issues, Columbia Memorial Hospital became interested in the viability of a physical medicine and rehabilitation specialist in Astoria. One of the most significant factors to the success of physiatrist is whether this specialist can obtain referrals from primary care clinicians. The purpose of this study was to assess the attitudes, potential competition, past referral patterns, and predicted referral patterns of clinicians in Astoria and Seaside with respect to physiatry. The majority of surveyed clinicians self-report a high degree of familiarity with physiatry. They are comfortable referring patients to this field and they believe physiatry would provide unique services to the area. While some are concerned about competition with a physiatrist, the overall attitude from local clinicians is supportive of this addition to Columbia Memorial Hospital. While an adequate referral base may exist locally, the catchment area for this specialty can extend beyond Astoria and Seaside to ensure a sustainable number of patient encounters. Educating primary care clinicians about physiatry and cultivating relationships with colleagues in the service area should provide adequate referrals to support this addition to Columbia Memorial Hospital. 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. Difficulties in Narcotic Prescriptions for Chronic Pain Patients in a Rural Clinic Project Date: 3/17/2008 Background : It is difficult and time-consuming for different providers in a small rural healthcare practice to determine when a pain medication is due for a patient under a narcotic contract, because of different levels of patient understanding and variability in the wording within the prescriptions. Furthermore, the dispensation of narcotics causes significant tension in the doctor patient relationship. Question: I set out to determine if there was a way to improve the communication between a patient and a provider and among different providers in a group. Methods: I conducted a number of interviews with staff and patients and used the GE Centricity electronic medical record to better define the population with narcotic prescriptions within the practice, and then attempted to use the electronic medical record to generate uniform narcotic prescriptions. Results: The population receiving narcotics prescriptions in this practice were disproportionately Medicaid and Medicare patients. Although prescribing practices varied significantly among providers, the idea of creating a uniform disclaimer for narcotics prescriptions was met with enthusiasm. Therefore, a quick text generator, or “dot phrase” was created that could be entered into a prescription that read “Do not refill. Do not drink alcohol while taking this prescription. Do not operate a motor vehicle if impaired. Limit to Applegate Medical Providers. Limit to _______ Pharmacy. This medication is to last until ________.” This was then linked into the patient’s medication chart, the current visit note, and the after-visit summary. Although this was not a complete solution, the project was viewed as a success by groups prescribers Use of Vicscosupplementation in Patients Suffering from Osteoarthritis of the Knee: Improving Outcomes for the Patients of Klamath Family Practice Center Project Date: 10/15/2007 Osteoarthritis is a widespread problem, especially among older adults. Due to the pain and immobility associated with the condition its effect on quality of life is often detrimental. The relatively large number of patients seen for osteoarthritis at the Klamath Family Practice Clinic made the relevance of osteoarthritis treatment to the Klamath Falls community quite clear. The rural quality of the community adds a further level of importance, since employment and household responsibilities tend to be physical and dependent upon mobility. Hyaluronic Acid injections are a relatively new form of treatment of osteoarthritis of the knee. They represent a new tool for primary care physicians in helping their patients to overcome the disabling effects of osteoarthritis of the knee. I interviewed a number of patients who had received the Hyaluronic Acid injections and a pair of doctors who have given the injections to their patients to assess the efficacy and subjective value of this therapy. I also reviewed current literature on the therapy. Research showed that the injections are moderately effective in controlling pain and improving mobility, with better duration of effect (up to ~12 months) than current non-surgical therapies. Subjective data showed a large perceived benefit for most patients and doctors utilizing the treatment, with exceptions tending toward patients with more advanced disease. 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. Increasing Exercise in Reedsport. Project Date: 7/2/2007 Exercise can help prevent and improve many chronic conditions. Reedsport, a small town on the Oregon coast, offers an incredible venue for an active lifestyle – there are lakes, rivers, sand dunes, beaches, pools, gyms and great trails for walking. Family practice physicians at Dunes Family Health Care (DFHC) in Reedsport spend a considerable amount of time counseling patients on the benefits of exercise. Despite the encouragement of the healthcare community and the favorable environment for physical activity, many of the patients at DFHC struggle to incorporate exercise into their daily routine. To help address these issues, I created www.reedsportwalks.com - an interactive, self-sustaining, online forum to help the Reedsport community lead a healthy, active life. The site contains information regarding the importance of exercise, how to start exercising by setting reasonable goals, and how to overcome barriers like chronic pain and time constraints. There is also a comprehensive list of exercise ideas specific to Reedsport including a walking map of the surrounding area and schedules for the pool and local gyms. The site was set up as a google group, making it easy to access, self-sustainable, and interactive. Ideas on how to expand the site include: publishing a page on specific exercise ideas for kids and teens, organizing a community fitness event or weekly walking group, or expanding the site to include healthy options for eating out in Reedsport. 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. Charting Chronic Pain in Grant County Project Date: 5/1/2006 In the primary care practice of Dr. Robert Holland and Dr. Russell Nichols in John Day, Oregon, chronic pain visits occupy an average of 4-5 visits per day and these patients see the doctor 2-3 times more frequently than other chronic pain patients. The age distribution of Grant County is becoming top-heavy, with those >65 years old comprising 17.1% of the population, nearly five percent greater than the national average. Additionally, the number of manual laborers and individuals participating in outdoor activities that are tough on their bodies is commonplace in this population. Hence, the development of a standardized form for charting frequent pain management visits for musculoskeletal, neuropathic, fibromyalgia, longstanding post-surgical pain, and chronic narcotic use can save both time and money for a busy primary care practice. The average cost savings per physician in the practice from using a form rather than dictating progress notes from chronic pain visits is approximately $772 per year. Efficacy of this form is likely to be seen more in a rural setting due to the fact that there is little turnover of the population and few doctors, so there is greater longitudinal data collection. Optimal use of the form will allow for concise, long-term data collection and more focused pain management strategies that improve both the patient and physician satisfaction. 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. 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. Chronic Non-malignant pain in a rural primary care clinic Project Date: 11/10/2003 Problem: Treatment of chronic non-malignant pain (CNMP) is a common and often frustrating aspect of primary care medicine. Limited time may be lost to technical talks done in the office, impacting the preventative or screening services Chronic Non-malignant Pain Patients (CNMPPs) receive. A proposed ORPRN project will explore concerns that more time is spent on texhnixal tasks in a CNMPPs' office visit, and less time spent on preventative services and other activities designed to encourage the patient's active participation in their own health. Additionally, this project considers how technical tasks, such as prescribing narcotics and monitoring compliance, impact physicians' attitudes toward treating CNMPPs. Population: 7 MDs and 1 NP at Dunes Family Health Care Clinic (DFHCC) surveyed on their CNMPP population. Methodology: CNMP Questionnaire. Findings: Health care providers express frustration over certain aspect os CNMPP management, however concerns over CNMPPs receiving poorer quality of preventative or screening sercixes is of xonxcern to only about half of those health care providers surveyed. The Treatment of Chronic Pain at the West Salem Clinic Project Date: 11/4/2002 Chronic pain is a commonly encountered patient problem in any primary care setting. Over the last decade, the treatment of chronic pain has undertaken a multidisciplinary approach spanning beyond analgesics and surgical interventions to include alternative therapies, physical and occupational rehabilitation, and mental health services. The West Salem Clinic patient population is composed of mostly low-income and homeless patients, many of whom suffer from chronic pain. The purpose of this study was to ascertain what interventions this specific patient population has received for the treatment of chronic pain and compare these treatments to the suggested multidisciplinary approach. Chronic pain patients were asked to complete an anonymous survey regarding pain treatments used. The study found that despite being financially challenged, a large percentage of these patients had received some form of alternative treatment (chiropracty, massage, or acupuncture) and would continue to pursue such treatments if access was provided. The West Salem Clinic chronic pain patients also underutilized mental health resources, including individual, group, spiritual counseling, and antidepressant use. This underutilization was surprising to the physicians given that mental health services are available through the clinic. This study helped focus attention on the need for mental health counseling and treatment in chronic pain patients of this population and generated renewed interest in the offering of such services to these patients. Usefulness Of Medication Contracts In Treatment Of Chronic Pain Project Date: 7/2/2001 The epidemiological characteristics of 25 patients with chronic pain on medication contracts who are receiving care at West Salem Clinic were studied through a 16 question survey. Furthermore, the effectiveness of their pain management and their overall satisfaction with their care before and after signing a medication contract was assessed. We found that of the patients on medication contract the majority were Caucasian females between the ages of 40-60 who are unemployed and have an educational level up to college. We also found that the 84% of the patients felt that their pain was inadequately controlled before a medication contract and that 82% were dissatisfied with their care. Currently (after being on a medication contract) 47% felt their pain was not being controlled and only 23% were dissatisfied with their care. Based on these observations, it is possible that medication contracts directly or indirectly have a positive effect on the management of patients with chronic pain issues. Back to subject search page or search by preceptor site