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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 Implementation of a multidose naloxone protocol in a rural volunteer emergency medical service: a safety-diven quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Overstreet, Riesa Rachael; Chairperson, Graduate Committee: Stacy Stellflug; This is a manuscript style paper that includes co-authored chapters.Background: Opiate overdose (OOD) deaths are increasing in Montana. Emergency medical technicians (EMTs) are the primary prehospital providers in rural areas and the first contact for many OOD patients. In the last ten years, many states have added naloxone administration to the EMT scope. Now, EMTs administer a third of the naloxone given nationally. Local problem: A rural volunteer EMS experienced patient contact times longer than the duration of naloxone's action. State protocols allowed EMTs to administer one dose of intranasal naloxone. Methods: The Iowa Model--Revised guided the quality improvement (QI) project, which aimed to provide standardized, evidence-based interventions to improve the identification and treatment of patients with OOD, expedite their arrival at definitive care, and ultimately improve patient survival. Interventions: The project team created an evidence-based multidose OOD protocol for the volunteer EMS based on the EMT, scope of practice, and the practice environment. Naloxone and protocol training, badge cards, and substance use identification training supported the protocol implementation. Results: Overall, EMTs reported protocol use for patients with any signs and symptoms of OOD 71% of the time, increasing throughout the implementation period. Fifty percent of patients with evidence-based OOD signs and symptoms received naloxone. Conclusion: The QI project demonstrated that volunteer EMTs could apply the protocol to identify and treat patients with evidence-based signs and symptoms of OOD with similar accuracy to EMS providers nationally. Interdisciplinary partnerships in resource-limited rural settings can support QI efforts and increase the representation of rural populations in the literature.Item Improving health outcomes by reducing vitamin D deficiency in a rural clinical setting: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Pollard, Saije Madisen; Chairperson, Graduate Committee: Julie Ruff; This is a manuscript style paper that includes co-authored chapters.Vitamin D deficiency strongly correlates with high morbidity and health risks such as fatigue, mood irregularities, and muscle weakness. As of 2023, there are over one billion people of various ages suffering from vitamin D deficiency (Almuqbil et al 2023). A rural Wyoming clinic lacked a standardized process to screen for vitamin D deficiency, yet the condition is highly prevalent within their patient population. This quality improvement project aimed to implement a standardized vitamin D screening process within the rural Wyoming clinic. Patients were screened and offered a blood draw to obtain their vitamin D levels at each office visit. If applicable, patients were offered vitamin D supplementation. In concurrence with the lab draw, patients were asked to fill out a PHQ-9, GAD-7 and Fatigue Severity Scale (FSS) to track their mood and energy levels. The lab draws and screening questionnaires were repeated after eight weeks of supplementation. Screening for vitamin D deficiency improved from less than 20 percent prior to implementing the standardized process to over 90 percent after eight weeks of implementation. There was no significant correlation between PHQ-9, GAD-7, FSS and vitamin D levels. Eight individuals received the eight-week lab draw and 62 percent of these individuals had optimal vitamin D levels, 70-100mg/dL. The standardized vitamin D screening process was successful in increasing quality and frequency of screening; however, a significant correlation between mood, fatigue, and vitamin D levels was not found.Item Improving new patient cancer treatment education: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2024) Wilcox, Jamie Michelle; Chairperson, Graduate Committee: Elizabeth A. JohnsonBackground: A cancer diagnosis invokes high levels of uncertainty and anxiety. Healthcare professionals task themselves with providing appropriate education to help patients traverse their cancer treatment experience. Effective communication and educational interventions help patients acquire appropriate coping strategies to manage the disease process and reduce uncertainty. Purpose: This project aimed to improve patient satisfaction and decrease anxiety and uncertainty through an enhanced patient education process. The project took place in a rural outpatient oncology center. Participants included newly diagnosed oncology patients receiving intravenous (IV) chemotherapy/immunotherapy and clinic staff. Method: This project used the Demming Cycle quality improvement method. The education components drew on the guidance of literature reviewed for best practices and national guidelines for patient education and teaching techniques. Data obtained through surveys from patients and RNs, observations from the project lead, and additional feedback from staff informed the development of the education visit components. Intervention: A nurse education visit was scheduled the week before IV treatment started and included a learning needs assessment, clinic tour, education on port-a-cath care, regimen-specific side effects and self-management, and how and when to contact the healthcare team. Nurses provided content using the teach-back method. Results: Patient and staff completed surveys over six weeks of implementation. Sixteen patients completed surveys. 100% (n=16) were confident they could manage their symptoms at home after the education visit. Thematic findings from survey responses regarding the most valuable education piece included Theme 1, logistics of treatment; Theme 2, anticipated side effects and management; Theme 3, other value of knowledge and education regarding managing the disease process. Nine nurses were surveyed 17 times during the project, with each nurse completing 1 to 2 education sessions. 88% (n=17) of nurses surveyed felt the education visit improved from the previous system, and 71% (n=17) of nurses found the teach-back method was supportive of patient outcomes surrounding patient education. Conclusion: Providing a structured education visit for new oncology patients receiving chemotherapy/immunotherapy improved patient confidence in identifying and managing symptoms and side effects of therapy at home. The teach-back method reinforced the education content and demonstrated an understanding of the material.Item Implementing standardized depression screening for adults in a rural setting: a quality initiative(Montana State University - Bozeman, College of Nursing, 2024) Downing, Kjersti Lee; Chairperson, Graduate Committee: Stacy Stellflug; This is a manuscript style paper that includes co-authored chapters.Background: Major depressive disorder (MDD) imposes a significant burden, affecting 15-17% of the population. Early detection and intervention are crucial to mitigate adverse health outcomes associated with untreated depression. Clinical guidelines recommend regularly screening patients for depression within the primary care setting. The Patient Health Questionnaire (PHQ) is a widely recognized and validated tool used for depression screening. Local Problem: A rural clinic in Eastern Montana elected to implement a standardized process for administering PHQ-2 and PHQ-9 assessments to their adult primary care population. Methods: The Iowa Model guided the implementation process over eight weeks. Intervention: Nursing staff administered a PHQ-2 to eligible adult patients during primary care appointments. A PHQ-2 score of > or = 3 triggered the nursing staff to administer the PHQ-9. Positive PHQ-9 scores (> or = 5) prompted provider notification and subsequent evaluation for depression. Patients diagnosed with depression or other mental health concerns received appropriate interventions and treatments based on clinical expertise. Data was collected and deidentified before entry into a spreadsheet for further analysis. Results: Nursing staff administered a PHQ-2 to 71.8% (n=326) of eligible patients over the eight weeks. Of those screened, 46 had a positive PHQ-2 result, and 30 had a positive PHQ-9 result. Providers evaluated 100% of patients with a positive PHQ-9, and all were determined to have varying severities of depression. Conclusion: The findings supported the efficacy of the PHQ in identifying depression within a primary care setting. Moreover, these measures promise to enhance mental health care delivery and outcomes in the rural primary care setting.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 Development and implementation of a new referral process and dot phrase technology for a rural medication therapy management program to improve patient safety(Montana State University - Bozeman, College of Nursing, 2023) Scott, Jonathan Muir; Chairperson, Graduate Committee: Margaret HammerslaNo medication or procedure will cure dementia, and most patients will experience behavioral and psychiatric symptoms as the disease progresses. Medications to treat the symptoms of dementia are complex. Medication therapy management is a patient-centered collaborative agreement between provider and pharmacist that has shown positive outcomes in reducing adverse drug reactions. In January 2021, an outpatient clinic in Southwest Montana implemented the Rural Access to a Psychiatric Pharmacist for Seniors (RAPPS), an MTM pilot program to address the complex medication-related problems of elderly dementia. During the RAPPS process, an internal review identified two major concerns: (1) clinical information being communicated from provider to pharmacist needs to be more consistent and (2) the current system lacks a clearly defined referral process. This ongoing process improvement project used four Plan-Do-Study-Act cycles to develop, implement, and evaluate the dot phrase. A dot phrase is a section of text to be inserted into an electronic health record progress note. The dot phrase's utilization was analyzed at three different timepoints over the project's 6-week implantation period. A five-question visual analog scale provider-satisfaction survey was developed to be conducted at the fourth PDSA cycle. Preliminary data collected from the electronic health record from November 2022 to December 2022 found that 45% of providers' notes at the time of referral did not document a psychiatric diagnosis, and 81% of the notes did not confirm or deny outside psychiatric management. The primary, secondary, and tertiary SMART goals were not met. The QI project encountered many unforeseen problems throughout this study. The preliminary data collected in this project demonstrated that documentation deficits are occurring between providers and the clinical pharmacist. As more and more of our medical information becomes digital, health professionals will require additional training to become proficient in using these systems. IT systems are complex and challenging, so future quality improvement projects should have a dedicated IT specialist on their team. For collaborative agreement programs to succeed, clear communication between all stakeholders must be championed. Future research should examine technologies that encourage interprofessional communication within electronic referral systems.Item Medical flight handoff: a quality improvement project(Montana State University - Bozeman, College of Nursing, 2023) Sunden, Peter Scott; Chairperson, Graduate Committee: Alice RunningBackground: Flight medicine, transporting patients from small facilities over long distances, is essential in rural areas. Providing pertinent patient information to receiving care teams is critical and evidence suggests that over half of the pertinent patient information is omitted. Problem: Incomplete patient information provided by the flight medicine community can negatively impact patient safety and receiving team care. Methods: This QI project intended to increase efficiency of patient handoff to receiving care teams by way of a "drop sheet". The drop sheet was developed using the Mechanism Injuries Signs/Symptoms Treatment (MIST) mnemonic. One carbon copy of the drop sheet was left with the receiving nurse; the flight crew retained the other. A QR code was printed at the bottom of the drop sheet linked to a Likert-type survey assessing the comfort, completeness, timeliness, and effectiveness of the flight crew's patient handoff. Interventions: Training on the drop sheet and survey coincided with the project roll-out January 10th, 2023. Flight crews were instructed to complete a drop sheet on every patient and to leave a copy of the drop sheet with staff on the receiving team. Results: At the projects conclusion, (03/10/2023), 64 flights were completed; drop sheets were used 67% of the time. Four surveys were completed during the data collection time. Conclusions: According to the literature, consistent information provided by flight crew handoffs can improve patient safety and report completeness to the receiving care team. Drop sheets were successfully utilized though receiving care team satisfaction with the process remains inconclusive.