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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 The mental wellness conversation curriculum: better understanding the gap between facilitator training and community conversations(Montana State University - Bozeman, College of Education, Health & Human Development, 2024) Sutphen, Katharine Nora; Chairperson, Graduate Committee: Michelle U. Grocke-DeweyThis thesis whether the MSU Extension Mental Wellness Conversation Curriculum (MWCC) is effective in terms of adequately preparing newly trained facilitators to lead their own community based MWCC conversations. The MWCC is a mental health and wellness conversation pedagogy designed to be delivered in rural communities by community volunteer facilitators. The Social Ecological Model (SEM) explains the nuance of this program and incorporates supporting studies that leverage community-based and volunteer-led techniques. The results from the volunteer training evaluation data, a pre-and post- survey, indicate a positive change in awareness, knowledge, and beliefs among the 24 facilitators regarding specific mental health and wellness content presented in the training. The results indicate high favorability from volunteers regarding their experience at the MWCC training and optimism about the future of MWCC as a mental health and wellness program. However, despite favorable and statistically significant improvements from pre and post training data, there has been stagnation among community volunteers leading their own MWCC conversations. In response to this finding, a follow up exploration into possible explanations was conducted. Results indicated the importance of volunteer training as a predictor of volunteer engagement success. Additionally, the following themes were explored to understand the impact they had on MWCC volunteer engagement: 1) the duality of agency and autonomy in volunteering, 2) the explanatory power of the Self-determination Theory as it relates to volunteer motivation, 3) the importance of volunteer recruitment strategies and clear objectives, 4) the value of skills-based volunteering, and 5) the importance of content delivery within a training to maximize future engagement. Minor adaptations to the MWCC training and evaluation efforts would be beneficial for improved volunteer engagement going forward. Future research suggestions include further exploring how social context and environmental factors may impact the success of community based MWCC conversations.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 Risk mitigation focused on surgical care using process improvement methodologies in rural health systems(Montana State University - Bozeman, College of Engineering, 2023) Sitar, Nejc; Chairperson, Graduate Committee: Bernadette J. McCrory; This is a manuscript style paper that includes co-authored chapters.Rural healthcare is represented by approximately one-third of community hospitals in the United States primarily in the Midwest and Western United States. Due to the lack of resources and the demographic characteristics of rural populations, rural community hospitals are under constant pressure to meet Center for Medicare & Medicaid Services (CMS) quality requirements. Meeting CMS quality requirements is particularly challenging in surgical care, due to the lower volumes and research opportunities, in addition to a shortage of qualified surgical specialists. The perioperative surgical home (PSH) model was established as a health management concept in a rural community hospital located in the Northwest of the United States to improve the quality of care by providing a longitudinal approach to patient treatment. The main opportunities for PSH improvement were identified in the "decision for surgery," "preoperative," and "postoperative" stages of the PSH model. To improve PSH clinic performance this thesis proposes an improved National Surgical Quality Improvement Program (NSQIP) calculator User Interface (UI), as well as a new prediction model for predicting total joint arthroplasty (TJA) Length of Stay (LOS). The improved layout of the NSQIP calculator was developed based on two approved surveys by card sorting and Borda count methodology, while the new prediction model for predicting TJA patients' LOS was based on the Decision Tree (DT) machine learning model. A usability study of the NSQIP calculator UI identified opportunities for future improvements, such as the reorganized layout of postoperative complications and the addition of a supporting tool that would clearly define postoperative complications. The new DT prediction model outperformed a currently used NSQIP calculator in the prediction accuracy of TJA LOS, as it resulted in lower Root-mean-Square-Error values. Furthermore, the structure of the DT model allowed better interpretability of the decision-making process compared to the NSQIP calculator, which increased the trust and reliability of the calculated prediction. Despite some limitations such as a small sample size, this study provided valuable information for future improvements in rural healthcare, that would enable Rural Community Hospitals to better predict future outcomes and meet the strict CMS quality standard.