Health Care for the Future: Growing the Family Practice Clinic Report to the Community From the Wahkiakum Family Practice Clinic Advisory Board October 2008

Appendix 2 -Regional Medical Resources

The southwest portion of Washington and the northwest portion of Oregon are home to some significant medical resources that may provide benefits to Wahkiakum County and the Family Practice Center’s patients. In addition to St. Johns Hospital in Longview, there are two additional hospitals in the Lower Columbia Region.

Ocean Beach Hospital and medical clinics are located in Ilwaco, Washington, approximately 52 miles from Cathlamet. This is a full service hospital with 25 licensed beds, a 24/7 Emergency Department, as well as clinics covering internal and family practice, women’s health, orthopedics, minor surgical procedures, diabetic management, well child check ups, immunizations, and urgent care. Ocean Beach Hospital also has a satellite clinic in Naselle, Washington.

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cross the Columbia from Naselle, Washington, Astoria is home to Columbia Memorial Hospital. This is a full service, 25 bed, critical access, Level III Trauma Center. Operating in Astoria since 1880, this hospital is an important facility that is undergoing a major expansion. A 38,000 square foot Health and Wellness Pavilion opened May 2008 and includes a new Urgent Care facility. This hospital also maintains a 24/7 emergency department, as well as a full range of diagnostic and medical services and clinics.
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n Vancouver, Washington, there are two additional hospitals of importance. First, the Southwest Washington Medical Center is the regions medical control hospital. This institution is the oldest hospital in the region, established in 1858. Southwest is licensed for 360 board certified beds, with an additional 82 beds approved by the state. With an active staff of more than 600 physicians and 3,200 highly skilled supporting professional staff, this is the largest hospital in the area. Recently, the Firstenberg Tower project added 307,000 square feet to the hospital complex, including 154 beds, significant new heart and vascular care features, two dedicated open heart surgery suites and 13 new trauma, general and orthopedic surgical suites. This is a Level II Trauma Center and provides critical services to patients from throughout the region.
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he newest hospital in the region is also in the Vancouver area. Legacy Salmon Creek Hospital is one of the most technologically advanced hospitals in the region. The hospital opened in 2005, with 161 beds in a 460,000 square foot facility. With state of the art diagnostics, almost paperless patient record systems, and a full range of clinics and services, Legacy at Salmon Creek provides an additional medical resource to the region. There is a 24/7 Emergency Department, eight state-of-the-art surgical suites, and a family birthing center. Additional clinics focus on pediatric, women’s health, cancer care, cardiac care and intensive care. Legacy Salmon Creek offers the only level IIIb neonatal intensive care services in southwest Washington. The Salmon Creek facility is part of a larger system of hospitals including Emanuel, Children’s, Good Samaritan, Meridian Park, Mount Hood hospitals and their associated medical clinics. With more than 8,500 full and part-time employees, Legacy is one of the largest employers in the Portland – Vancouver metropolitan area.
Beyond these regional assets, there are two major universities with major teaching hospitals in Washington and Oregon. The University of Washington’s Harbor Medical Center is the only Level 1 adult and pediatric trauma center serving Washington, Alaska, Montana and Idaho. Harborview is one of the regions most comprehensive hospital facilities. As a component of the University of Washington Medicine, it is affiliated with the Universities Medical School, UW Physicians, UW Medicine Neighborhood Clinics, as well as the Children’s University Medical Group and the Cancer Care Alliance.
In addition, Portland, Oregon is home to the Oregon Health and Science University. This is a world class medical education institution. OHSU includes schools of medicine, dentistry, nursing, science and engineering, and pharmacy. OHSU is also a Level 1 Trauma Center, and had approximately 11,500 employees and 2,553 students in 2004. With additional clinics and hospitals throughout the state, OHSU is a critical medical institution for the entire state of Oregon. Many patients requiring specialty care travel from southwest Washington to the OHSU facilities in Portland for their care. Most OHSU facilities in Portland are approximately 90 miles from Cathlamet.

Appendix 3 - Clinic 2007 Survey

Overview
The Clinic Advisory Board conducted a survey of all Box Holders in Wahkiakum County and on Naselle Rural Route #1. Approximately 2,200 surveys were available. There were 2,179 mailed to Box Holders and the remainder were available at the Clinic and the Commissioner’s Office (3^rd Floor Courthouse).
This is not a scientific survey, nor can the data be considered as representative of the entire population. Looking at normal human motivations, those to whom the Clinic is very important are the most likely to respond. Therefore, there is probably a bias toward those people. However, those who find the Clinic is very unimportant to them are also motivated to reply, so that their interests will not be overlooked.
As of March 5, 2017, the total number of surveys received and recorded is 422. This is return of 19.2 percent of the total possible surveys made available. However, we allowed people to make copies of the survey, making this percentage somewhat imprecise. It is a decent return by survey standards. Experience in Wahkiakum County without other Box Holder surveys is often much lower, suggesting this survey was of interest to more people.
Methods
The survey data were entered manually into Survey Monkey. This is a tool for gathering information via the Web. It provides a very reliable way of recording and verifying survey data against paper records. Therefore all the data was recorded in this tool. There was one survey returned that was destroyed by the mail processing machine and could not be read. It was not counted in the total.
All comments were captured verbatim. Occasionally, the recorder added a word in parentheses to clarify meaning of the response. All responses were analyzed using a scoring system and the themes summarized.
Findings
Question 1: Importance
Question 1 asks the responder how important the Family Practice Clinic is to them. The following frequency distribution summarizes the data. Please note that 12 respondents did not answer this question.

Chart 1. Clinic Importance

Thus, 65% of those responding said the Clinic is very important to them. The majority of the remaining respondents said that the Clinic is somewhat important to them (15%) or is very unimportant to them (9.2%).
When exploring how respondents addressed Question 1 and the other questions, some initial observations are provided below.

Table 1: Importance Vs Option Selection and Subsidy Selected

Importance	Very Important	Somewhat Important	Neither	Somewhat Unimportant	Very Unimportant
Option 1	22	13	14	1	1
Option 2	72	30	1	2	1
Option 3	157	7	1	0	1
Option 4	16	14	3	4	3
Subtotal	264	63	19	7	6
Patient Fee	92	39	17	5	30
Tax	51	7	0	0	0
Combination	113	10	1	0	0
Other	8	5	1	2	8
Subtotal	264	61	19	7	38

When looking at how important the Clinic is to the respondent there is definitely a strong relationship with the option selected and the type of subsidy recommended. That is, for those who stated the Clinic is very important to them, they also indicated that Option 3 – Full Service Clinic, is their service level preference and that a Combination of Fees and Tax should be used to subsidize the Clinic.

Now looking at how responders feel about the options, there is no clear winner selected. Those who find the Clinic Somewhat Important (63), said that a Mid-Level of Service was their preference (30, followed by Another Option (14) or Option 1 (13). For those same individuals, Patient Fee was by far the preferred method of subsidy (39). For the individuals who said the Clinic was Neither Important or Unimportant, Somewhat Unimportant, or Unimportance, there were only 32 replies. Of those replying, they tended to favor Option 1 or 2 (Basic or Mid-Level services) and strongly favored Patient Fees as the method of subsidizing the Clinic.
In the case of subsidy type, there is a second high frequency selection for Patient Fees. However, there is a stronger selection for Patient Fees for those responding in the somewhat important to very unimportant categories.
The two tables which follow show the data in Table 1 in graphic form.

Chart 2: Clinic Importance versus Clinic Option Selected

So once again, we see that the greatest number of respondents selected Option 3 (Full Services) and of those selecting Option 3, the great majority also stated that the Clinic was very important to them. For Option 2 (Mid-Level Services), there 105 responses in total and 72 of these stated the Clinic was very important to them. Those selecting Option 1 (Basic Services) included people who thought the Clinic was very important to very unimportant.

Chart 3: Clinic Importance versus Form of Subsidy Selected

Reviewing the Subsidy data again, we see that 186 respondents selected the Patient Fee as their preference if a subsidy is required. Of these 186 respondents, 94 also feel the Clinic is very important, 40 said it is somewhat important, 17 said neither, 5 said somewhat unimportant, and 30 said very unimportant. Consistently, these data show that most respondents find the Clinic is very important or somewhat important and most of these respondents want either a patient fee or a combination of fees and taxes to subsidize the clinic if a subsidy is required.
Question 2: Preferences
Question 2 asked individuals to indicate who they prefer to see when going to the clinic and also provided an opportunity for responders to state that they go to Kaiser or to another clinic. In this question, 17 people chose not to answer the question.
In Chart 4, which follows, the respondents stated their preferences for the type of Clinicians they would be will to see. Most respondents (31.3%) said they would be willing to see the next available Clinician. Twenty-seven percent said they would prefer to see the Doctor first. Many people offered explanations about what factors would determine their choice of Clinicians with most people indicated in a very severe illness or injury; they would prefer to see the Doctor first.

Chart 4. Clinician Preferences

In Chart 5, we see that there are 97 respondents who either go to Kaiser or another Clinic.

Chart 5. Respondents Going to Kaiser or Other Clinics

Question 3: Willingness to See ARNP
Question 3 asked respondents if they would be required to wait 2 or 3 weeks to see the doctor, would they be willing to see an ARNP. Fifty-eight respondents did not answer this question.

Chart 6. Willing to See ARNP

This question was meant to discover whether or not there is a need for patient education about the importance of being willing to see the next available clinician. The small number of individuals, who firmly stated no, they wanted to see a doctor, is encouraging. However, this question also generated 28 comments regarding the circumstances under which individuals might be willing to see an ARNP or need to see a doctor. The question results may be somewhat biased by the absence of context which would have helped the respondent understand the general purpose for the question. However, in general, it appears that most of those responding are receptive to seeing ARNPs.
Question 4: Service Level Preference
Question 4 asked the respondents to select the service level that made most sense to them. In this case, 24 respondents decided not to answer this question.

Chart 6. Service Level Selections

Most respondents selected Option 3 – the Full Service Clinic (39.5%). Twenty-five percent of the respondents selected Option 2 – Mid Level Service Clinic and 15.4% selected the Basic Service Level Clinic.
Fifteen percent of respondents selected the open-ended Other Option. They provided information about the nature of the option they wanted to see adopted. The summary of the 59 individuals who provided other options and ideas is presented below:

Table 2: Summary of Other Option Themes

Other Options Recommended by Group	Number
Sell the clinic, close the clinic, it is failing, or nothing/none	21
Find federal funding, make it a FQHC clinic, have Cowlitz take it over	8
Combinations of the options, do the best possible within funding	9
Privatize, return to private practice as before	7
Users of the clinic pay for services	3
Access to all for emergency care	3
Other	8
Total	59

The themes here are also repeated in the general comments offered by respondents in Question 7.

Question 5: Number in Household
Question 5 asked how many people were in the respondent’s household. Sixty-two respondents did not provide this information. The total number of individuals in the 356 households responding to this question is 805. This is equal to 20 percent of the county population (i.e., assuming the population is 4,000 per the Wahkiakum Cowlitz Council of Governments).
The average number of persons per household in the responding group was 2.3 persons per household. If we assume that the households not responding are the same average size, then we would add another 143 persons to the number of individuals covered by the survey. If this is correct, then 948 individuals were covered by the survey and that is equivalent to 23.7% of the county population.
Question 6: Methods for Subsidizing
Question 6 asked respondents to select a method for subsidizing the Clinic. They were also given the option of selecting other with an explanation. Twenty-two respondents did not answer this question.

Chart 7. Choice of Subsidy Type

By far the greatest support was for Patient Fees (45.5%), followed by a Combination of Taxes and Fees (29.6%). Almost 14% supported using taxes. Those who indicated other were required to give an explanation. Of the 25 respondents who selected other, 20 said that no subsidy or none of the above would be their choice.
Question 7: Comments
Question 7 provided an open-ended opportunity for respondents to make comments or observations. In some cases, where respondents had made notes next to questions 1 though 6, these notes were recorded in the comments section. Of the total respondents, 241 provided comments, observations, and/or asked questions in this section.
There are definite themes in the comments and observations. The text was reviewed and coded by theme. Some comments only reflect one theme or ask one question. Others include many themes, include a question, or a combination of these. The themes and the number of appearances of that theme are summarized in the table below:

Table 3. Summary of Themes and Observations

Code	Themes and Observations	Number
1	Need, prefer or would support Full Service Clinic	16
2	Believe that Mid-Level or Basic Service is best, what we can afford	15
3	Clinic is vital, essential to the community, do everything to keep it	43
4	Get rid if it, sell it, if it isn’t self-supporting close it	33
5	Must be private, get government, the Commissioners out of it	38
6	Clarifying when willing to see ARNP and when wants to see doctor	28
7	Clarifying when fees or taxes are recommended and why, suggesting other funding sources, cutting other programs to keep the clinic	43
8	Keep Dr. Wright, return the Clinic to the way it was under Dr. Richard Avalon or Dr. Phil Avalon, return to the way it used to be when it ran fine and wasn’t under public control	18
9	No taxes, not fair to property owners, not fair to those who can’t or don’t use the clinic to use a tax, can’t use a tax and deny services	55
10	Only use taxes for some support or all support if the Clinic is open to all residents of the county, especially for urgent care and emergencies	21
11	Too many people have been denied services, I’ve been denied services, unfair to select some patients, not others	17
12	I can’t/don’t use it but I still support the Clinic and am willing to be taxed	9
13	Find a new doctor quick, we need doctors	2
14	Improve or find new management	10
15	Other	15
16	The survey is poorly designed, unprofessional	4
Since many respondents addressed more than 1 theme, the numbers do not add to the total respondents providing comments.

In addition to these themes, 8 respondents reiterated in their comments that a FQHC is the best solution for the clinic. Two respondents were insiders and made specific recommendations about staffing levels, the building space, etc. Finally, there were several questions asked. Many respondents did not understand the composition of the patient base suggesting that the figure must be too high (i.e., did not think that individuals from outside the county would be included). These and the other questions should be address in the final report.

Conclusions
For those responding to this survey, a significant majority stated that the Clinic is very important to them. When looking at the data, it is clear that most respondents are willing to see the next available Clinician and understand and value ARNPs. There were 97 respondents whose families go to Kaiser or another Clinic.
When looking at the service level options respondents selected, there is again a significant preference for a Full-Service Clinic. Those who find the Clinic is very important to them are also very likely to support the Full Service Option. Of all respondents, only 59 did not select Option 1, 2, or 3. Therefore, there is strong support for retaining the Clinic in some form in the responder group. Of those who offered other options, only 21 were outright recommending closing or selling the clinic.
When examining preferences for how to subsidize the Clinic, most people suggested a Patient Fee, follow closely by a Combination of Fees and Tax.
In the comments provided by responders, the top 5 themes included the following:

• 
  No taxes, not fair to property owners, not fair to those who can’t use the Clinic, can’t tax and deny services (54)
  
• 
  The Clinic is vital, essential to the community (43)
  
• 
  Clarifying when fees or taxes are recommended and why (42)
  
• 
  Must be private, get government, the Commissioners out of it (37)
  
• 
  Get rid of it, sell it, it must be self-supporting (33)
  

It is important to note that each responder who commented could make multiple comments. Each individual theme was coded and most comments included at least two themes.

These factors should be considered in shaping the recommendations for the Clinic.