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Item Implementation of a mental health pre-visit process in a rural primary care clinic: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Kaufman, Tori Rae; Chairperson, Graduate Committee: Jamie M. Besel; This is a manuscript style paper that includes co-authored chapters.Background: United States rural residents have limited access to mental healthcare. Nearly half of Montana's population is designated rural. Maximizing resources in resource-deficient regions requires creative strategies and process implementation to streamline workflow to achieve sufficient care. Local Problem: A rural Eastern Montana primary clinic has attempted to address its rural community's limited mental health resources by employing a psychologist. There is no new mental health patient pre-visit process at the project site. The purpose of the project was to implement a pre-visit process to improve the psychologist's ability to effectively care for the patient population. Methods: The Iowa Model Revised guided this quality improvement (QI) project. Process changes evaluations occurred at week three, week six, and postintervention. Interventions: A new mental health patient pre-visit process and packet were created, including a standardized Mental Health History Questionnaire (MHHQ). Educational in-services and staff completion checklists were performed to promote adherence to the process change. Results: The project goals were achieved: 95% of the new mental health patient pre-visit packets were mailed within two days of referral acceptance, 75% of new mental health patients returned their MHHQs, and 100% of staff reviewed and signed the new mental health patient pre-visit process. Conclusion: The project improved the psychologist and staff's new mental health patient workflow process. The psychologist noted an increase in patient preparedness and satisfaction, a decrease in time to diagnosis/treatment, and a slight decrease in the initial mental health evaluation duration.Item Improvement of cervical cancer screening in a rural primary care setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Kelleher, Katie Carla; Chairperson, Graduate Committee: Amanda H. Lucas; This is a manuscript style paper that includes co-authored chapters.Background: Cervical cancer (CC) is the fourth most diagnosed cancer among women. Cervical cancer screening (CCS) is a vital component of routine health care, as any individual with a cervix is at risk of developing cervical cancer, and nearly all diagnoses of aggressive cervical cancer are directly associated with a lack of screening, underscreening or inadequate follow-up of abnormal results. Unfortunately, the number of women overdue for CCS continues to increase gradually nationally and in Montana. Local Problem: At a rural primary healthcare clinic in northwestern Montana, 37.0% of patients have a current CCS completion documented, compared to Healthy People's 2030 benchmark of 84.3%. Methods: Participants included female patients ages 21-65 who presented to the clinical for an annual exam. Using the Plan-Do-Study-Act cycle, the intervention outcomes were measured biweekly throughout the six-week initiative. Measures assessed included: Adequate CCS eligibility determination, proper CCS documentation with the EHR, and the overall site CCS completion percentage. Data was collected over six weeks, de-identified, and analyzed using percentages and bar graphs. Interventions: Literature supported a multifactorial approach to standardize workflows and documentation practices among the nurses and medical assistants (MA) through the provision of educational material and a CCS clinical decision tree. Key process changes included offering of same-day CCS screening, follow-up scheduling prior to the patient leaving, and EHR alert creation if patient records were requested. Results: A total of 30 patients presented to the clinic. 100% of patients who presented to the clinic were assessed for CCS eligibility. 100% of eligible patients were offered CCS. 84.6% of patients had correct CCS documentation by the staff within the EHR, with four patients lacking proper documentation. A 4.1% increase was seen in the overall facility CCS completion percentage, reaching a total CCS completion percentage of 41.1%. Conclusions: Implementing education, standardized workflows, and the use of the CCS clinical decision tree improved CCS documentation and completion rates.Item Intervention to increase advanced care planning: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Salley-Rains, Brittany Elizabeth; Chairperson, Graduate Committee: Amanda H. Lucas; This is a manuscript style paper that includes co-authored chapters.Background: Advanced Care Planning (ACP) is an ongoing process where medical provider(s) combine clinical expertise with patient values to plan for end-of-life. Successful ACP results in goal-concordant care; completion of advanced directives; and ensures satisfaction of Centers for Medicaid and Medicare Services (CMS) quality metrics. Local Problem: The ACP workflow, patient education, and ACP documentation at the project site was not standardized. Average satisfaction for CMS ACP Registry quality metrics, targeting adults 65 years or older, was 63% average for the previous three years, which fell below the 100% benchmark. Methods: The Plan-Do-Study-Act framework was used at a primary care office in the Western United States. A microsystem assessment and ACP quality metrics were reviewed pre-intervention. Descriptive statistical analysis of outcomes was monitored over five weeks. Interventions: Evidence-based interventions included: staff education; standard EMR documentation and template development; new ACP workflow and role delineation; and selection of standard ACP patient education material. Results: Seventy-five percent of staff received ACP education. Seventy-one percent of eligible patients received the ACP packet. The standard EMR template was used with 57% of eligible visits. ACP document completion and plan was prepared for 71% of eligible visits. Conclusion: Although project staff education, workflow, and EMR template improved ACP assessment and delivery by team medical assistants (MA), provider and MA use of the EMR template increased to only 57% as limited time and discussion occurred to necessitate documentation. All interventions were only partially adopted. Full adoption would require further support including the designation of a staff leader.Item Implementation of the patient health questionnaire- 2 & 9 adolescent modified [PHQ-2 & 9 A] in a pediatric clinical setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Mock, Devin Michael; Chairperson, Graduate Committee: Julie Ruff; This is a manuscript style paper that includes co-authored chapters.In Montana, the importance of pediatric depression screening within the pediatric primary care setting cannot be overstated, mainly due to the state's high prevalence of pediatric depression and unique rural challenges. Pediatric primary care is often the first line of defense in identifying and addressing mental health issues in children and adolescents. In such a vast and predominantly rural state, primary care providers play a crucial role in early detection and intervention, overcoming barriers such as limited access to specialized mental health services and cultural stigmas. Effective screening and early intervention strategies immediately benefit the child's mental health and contribute to long-term positive academic and social development outcomes. Integrating mental health services into primary care is essential for improving healthcare outcomes. The American Academy of Pediatrics' current guideline recommends that all children 12 years and older receive annual depression screening using a validated and reliable tool such as the Patient Health Questionnaire- 2 & 9 Adolescent Modified [PHQ-2 & 9 A]. Unfortunately, at an urban Montana pediatric primary care clinic, the number of pediatric patients receiving appropriate screening is below sub-optimal. A Plan, Do, Study, Act cycle was implemented throughout the clinic to increase pediatric depression screening rates through education, reminder-based systems, and standardized hand-off reports.Item Increasing POLST completion in patients 65 and older: a primary care quality improvement proposal(Montana State University - Bozeman, College of Nursing, 2024) Troxel, Katherine Denali; Chairperson, Graduate Committee: Margaret Hammersla; This is a manuscript style paper that includes co-authored chapters.The Physician Order for Life Sustaining Treatment (POLST) is a signed medical order, relied on when an individual is unable to communicate, or unaccompanied by a healthcare proxy; POLST protects individuals with active preferences to waive default life support interventions (Turnbull et al., 2019). Adults aged 65 and older require more emergency services than any other demographic, yet only 20% of injured adults requiring emergency transport have a POLST at the time of 911 contact (Zive et al., 2019). 25% of patients aged 65 and older receiving primary care at a rural, western Montana clinic have a POLST in the electronic medical record (EMR). A literature review of POLST expansion into the non-acute care setting was conducted to create a clinic workflow for POLST completion. Eight primary care providers were issued a discussion framework and EMR documentation aid. Number of new POLST were captured from the EMR bi-weekly. Patients 65 and older presenting for an annual wellness visit (AWV) were screened for POLST in the EMR. Provider offered POLST completion for those without and documented discussion regardless of completion. Those not ready to complete POLST were sent home with the document and offered a 2 month follow up appointment to complete it. 10.8% of qualifying AWVs (n=37) during the 30-day study period resulted in POLST completion. Provider guided POLST discussion promotes patient centered care in the event of an emergency. A longer study period, built-in EMR reminders, and an on-site POLST leader may increase metric compliance.Item Increasing recommended testing compliance for persons with type II diabetes in primary care(Montana State University - Bozeman, College of Nursing, 2024) Fleming, Brandi Lynn; Chairperson, Graduate Committee: Elizabeth A. Johnson; This is a manuscript style paper that includes co-authored chapters.Background: Type II diabetes affects one in 14 Montanans (Centers for Disease Control and Prevention (CDC), 2023). The CDC estimates annual direct and indirect costs of diabetes in Montana exceed $800 million (2023). Constraints persist when incorporating National Quality Forum measures and Healthy People 2030 objective guidance to address known challenges in managing Type II diabetes in a community setting due to minimal resources and lack of workflow appraisal. The rurality and radical weather patterns in Montana pose challenges for sustaining healthy diets and regular exercise. Purpose: The quality improvement project aims at generating consistent clinical decision support system (CDSS) electronic health record platform (EHR) reminders, streamlining workflow processes, and delaying Type II diabetes' concomitant conditions. Methods: A Plan-Do-Study-Act (PDSA) cycle employing Amazing Charts EHR to consistent clinical decision support system reminders, workflow process modification, and shared decision-making interventions. Purposive sampling included persons with Type II diabetes, 18-75 years, presenting for an annual visit type encounter. Interventions: Rule query preference entry and workflow process modification were monitored to a short-term goal benchmark of 90% for completion of recommended testing for persons with Type II diabetes. Data collection evaluated generation of CDSS reminders and annual completion of comprehensive foot examinations, urine microalbumin to creatinine ratio testing, and dilated eye examinations. Results: A total of six patients participated in the project, n = 5 met criteria for Type II diabetes diagnosis, n = 1 miscoded. The EHR generated CDSS reminders, and staff completed annual comprehensive foot examinations 83.33% of eligible encounters. Urine microalbumin testing was completed 66.63% of eligible encounters with n = 1 (16.33%) deferred testing until their annual visit. Strengths emerging from Strengths, Weakness, Opportunities, and Threats (SWOT) analysis included simple streamlined guidelines that promote teamwork. Conclusion: Consistent CDSS reminder facilitates recommendation completion, benefiting patients and providers. Although short term goals were not achieved at the 90% benchmark, the project is deemed clinically significant representing the homogeneity of Montanans. Future recommendations include participation in Merit-based Incentive Payment System (MIPS), extension of interventions for utilization of other chronic diseases, and integration of Current Procedural Terminology (CPT) codes for reimbursement for services.Item Provider applied fluoride varnish for pediatric populations within the rural primary care setting(Montana State University - Bozeman, College of Nursing, 2024) Black, Riley MacKenzie; Chairperson, Graduate Committee: Amanda H. LucasA six-week quality improvement project using the PDSA framework included an oral health risk assessment screening with the Oral Health Risk Assessment Tool (OHRAT) and fluoride varnish (FV) application training of primary care providers used as a preventative treatment for pediatric-age children within the rural health primary care setting. The intended outcome aimed to improve oral health assessments, opportunities for oral-health provider-to-parent education and enhance overall oral health for generations of patients. At the project conclusion, participation included thirty-nine [n=39] patients during phase I and twelve [n=12] during phase II. Due to repeat participation, n=5, patients were excluded. During phase I, 10.5% of participants received FV treatment, however, 71% refused FV treatment due to having recent dental care. In phase II, 68% of participants received FV treatment with 33% refusing due to recent dental care. The implemented workflow achieved an increase in the number of pediatric patients receiving FV treatment and risk screening versus the clinic baseline of zero. Due to low participation numbers, it is difficult to determine clinical effectiveness on overall long-term oral health outcomes. Changes in workflow measures clearly were an effective process that could be replicated as a financially feasible and worthwhile procedure to any primary clinical setting. The process promoted provider engagement with patient/parent oral health discussion which overall improved potential for access to dental care.Item Improving diabetic foot evaluations and podiatry referrals in primary care(Montana State University - Bozeman, College of Nursing, 2023) Holland, Courtney Alyssa; Chairperson, Graduate Committee: Amanda H. LucasDiabetic foot ulcers (DFU) are responsible for over 5% of diabetic deaths. DFUs can be prevented or delayed with early diagnosis and treatment of associated diabetic foot complications by utilizing annual comprehensive diabetic foot evaluations (DFE). Despite this, diabetics are not receiving evaluations per the American Diabetes Association's (ADA) recommendations on timeliness and completeness. The potential problem was identified and a needs assessment was undertaken to diagnose the need for change in practice. At one provider clinic in central Montana, less than two-thirds of diabetic adults received a DFE at their annual exam, compared to the national benchmark of 74.8%. Next, a literature review was utilized to gather and analyze evidence. The best solution was identified and a quality improvement project was proposed. Using the Plan-Do-Check-Act cycle, the outcomes were measured preintervention and weekly after implementation. Outcomes included: rates of Michigan Neuropathy Screening Instrument (MNSI), ADA risk assessment, DFE documentation, and podiatry referral completion. The 6- week project focused on nurse practitioner practice change including staff education, implementation of the DFE tools (MNSI and ADA risk assessment), documentation template, and new process flow. Podiatry referrals were included in the new process for patients who screened positive on the MNSI and ADA risk assessment. One hundred percent of patients received an MNSI, ADA risk assessment, documented DFE, and podiatry referral, when indicated. Only 96.67% of patients received an annual DFE that was congruent with the ADA guidelines, with one patient having an incomplete neurological exam documented in their chart. Improvement in rates of timeliness and completeness of DFEs and podiatry referrals were observed when utilizing these standardized assessments and processes. The project culminated in a reflective evaluation of how Montana State University's Doctor of Nursing Practice (DNP) program met the DNP essentials required for graduation.Item Screening and documentation of social determinants of health in primary care(Montana State University - Bozeman, College of Nursing, 2022) Hudik, Breanna Noel; Chairperson, Graduate Committee: Amanda H. LucasSocial determinants of health (SDOH) are the conditions of the environments in which people live, work, learn, and play that influence their overall health outcomes. The project's purpose was to increase SDOH screening and documentation in a small, family nurse practitioner-led, primary care practice where social needs were not routinely screened for or addressed during patient encounters. The patients participating in the quality-improvement project completed the 11-item Accountable Health Communities Health-Related Social Needs screening tool developed by the Centers for Medicare and Medicaid. The screening tool was provided to all new patients and patients scheduled for routine annual wellness care during a 7-week period. The completed screening tools were provided to the family nurse practitioner (FNP) to review and subsequently assign an International Classification of Disease (ICD) diagnosis code in the patient's electronic health record (EHR), if unmet SDOH needs were identified. The project also collected data on the number of eligible patients screened and the number of screening tools scanned into screened patient's EHRs. The results of the quality-improvement project include that 90% of eligible patients were screened for unmet SDOH needs, with 84% of those screening tools uploaded into the EHR. Lastly, the ICD diagnosis codes entered by the FNP were tabulated using a frequency table, and insufficient housing was the most frequently identified unmet SDOH need in the patient population screened. Insufficient housing accounted for 33% (4 of 11) of the total number of unmet SDOH needs identified. The quality-improvement project highlighted the importance of screening and documenting SDOH as they provide deeper insight into the complex role unmet SDOH plays in the overall health of patients. The project also shed light on future avenues the FNP can pursue to cater to needs identified in their patient population with the screening tool, including referrals to community resources such as affordable housing options or housing voucher programs.Item Increasing primary care providers' adherence with ADA guidelines for annual Urine Albumin-to-Creatinine-Ratio (UACR) screening in diabetic patients(Montana State University - Bozeman, College of Nursing, 2023) Senn, Chloe Lane; Chairperson, Graduate Committee: Alice RunningBackground: Diabetes affects over 34 million Americans in the United States, and in Montana, 9.1% of the adult population has diabetes. Diabetic kidney disease is the leading cause of end-stage renal disease, which can be easily identified and monitored by proper screening. Urine albumin-to-creatine ratio is a sensitive and early indicator for diabetic kidney disease and is essential for hindering the progression to end-stage renal disease. Therefore, the American Diabetes Association recommends annual urine albumin-to-creatine ratio screening for all diabetic patients. Problem: Compliance with urine albumin-to-creatine ratio screenings at a rural clinic in Eastern Montana was low at 29.8%, indicating a need for improvement. Methods: The project included initiating a trial protocol for ordering urine albumin-to-creatine ratio screenings, triggering a best practice alert within the electronic medical record for repeat urine albumin-to-creatine ratio screenings on positive (>30mg/g) patients, and tracking provider adherence over six weeks. The clinic set a goal of 80% compliance in ordering urine albumin-to-creatine ratio, 90% with confirmation testing on positive urine albumin-to-creatine ratio, with a long-term goal of preventing end-stage renal disease. Results: Provider adherence increased to 78.2%, slightly under the goal of 80%. Twenty-one patients screened positive for microalbuminuria. Only six had repeat testing, thus, making provider adherence to confirmation testing 28.6%. Conclusions: This project was beneficial in increasing the focus on screening for diabetic nephropathy. Implementing the trial protocol has improved the provider's adherence. Early detection improves the patient's quality of care, lowers the financial burden on the patient, reduces healthcare costs, and decreases the progression to end-stage renal disease.