Archive for West Virginia

Graduate Immersion Experience During West Virginia Flooding

Flooded streets and businesses in Clendenin, West Virginia

Graduate students in the School of Nursing’s Nurse Practitioner program Phil Dillard (Emergency) and Abby Wetzel (Nurse-Midwifery) discuss their immersion program experience with Cabin Creek Health Systems. The students worked alongside staff of the Clendenin Clinic to evacuate medically-fragile residents during the region’s recent storms and devastating flooding. Cabin Creek is a federally-qualified health center that provides essential health services to vulnerable populations in rural West Virginia through several community-based clinics.

 

Graduate Students Reflect on Immersion Experience during West Virginia Flooding

WV_Houses

School of Nursing graduate students participate every year in a two-week immersion program in West Virginia through the Lillian Carter Center for Global Health and Social Responsibility. Our students work in partnership with area federally-qualified community health centers to promote health and prevent disease throughout the region. Led by faculty Advisors Carolyn Clevenger and Debbie Gunter, students Andrea Brubaker, Phillip Dillard, Kimberly Eggleston, Hannah Ng, Jill Peters, Allysa Rueschenberg, and Abigail Wetzel, were providing essential health services through four community clinics located in cities to the north and south of Charleston. Two of our students, Phil Dillard and Abby Wetzel, were working in a clinic in Clendenin, a town 25 miles northeast of Charleston that was hit hard by the storms.

Phil Dillard discusses the experience in this WSB-TV Channel 2 interview. WSB Interview – West Virginia Flooding

Home from “The Holler” and Other Thoughts

This last post will come without photos and quotes, because our work in WV has ended. The administrators of Cabin Creek Health Systems (CCHS), saw our presentation and possible recommendations for our Quality Improvement project. Unfortunately, we couldn’t provide them with 3 bullet points on how to reduce hospital admissions for their patients with chronic illnesses. What will happen is probably better than rolling out prepackaged solutions.

Amber Crist, the Director of Education and Program Development has created and accepted the challenge of following up with 9 of the patients we were able to interview. Each patient’s provider will have the chance to do a home visit and get a more in depth understanding of their patient’s environment and social setting. This can help tailor the care plans needed to provide optimal health outcomes for patients at high risk for being re-hospitalized for primary care managed conditions. (Whew! That’s a mouthfull)

The coal miner we interviewed, will hopefully be able to get all the benefits he needs to cover his medical expenses. CCHS will also be getting a lung rehab center that will help ease the burden of COPD and other obstructive/restrictive pulmonary diseases for patients.

Ted Koppel, the famous British American news anchor, will be funding this project with CCHS. He will be reading my previous blog post, and watching the presentation Zane and the rest of the group worked relentlessly on this past week. We’re hoping the video serves as a tool to help spark a move to treat patients in a holistic approach, which will improve health outcomes for the community. This is just the beginning of bigger things for Cabin Creek Health Systems.

I’m excited to see what CCHS does in years to come. We were humbled. Learned lots….experienced great times in “The Holler”.

Thanks for reading, skimming, and browsing!

Ashleigh E. Heath, MPH
ABSN/MSN Candidate 2013/2014

 

A Coal Miner’s Story: From Weak to Running

My time in West Virginia has been a defining moment in my life. I knew nothing of the “Hollers” where residents of Cabin Creek live. It is a very different part of the country that is most likely invisible to the rest of the United States unless you have “kin” from the area. This all changed when I saw the lyrics to the old song “Sixteen tons”.

Scrip was used up until the 60s. This was the main form of currency in parts of WV. The company stores didn't accept US dollars.

Scrip was used up until the 60s. This was the main form of currency in parts of WV. The company stores didn’t accept US dollars.

“…I owe my soul to the company store” is posted on a museum. I’d heard this song as a child, sang the lyrics, yet never knew what it meant . The impact that the coal industry has had on West Virginia and other coal mining states is a part of US history that I didn’t appreciate until now. The company stores only accepted currency from certain coal companies. They owned the homes and land of all coal miners, and could take everything once you couldn’t work anymore. In a sense, their souls were “owned by the company store”.

Thousands used the coal industry to make a living, while sacrificing their lives and lungs to support our mostly excessive needs for energy. Black Lung Disease alone has caused severe morbidity and mortality for coal miners to the point that there are special health plans for those with the disease.

Some clinics were initially established to support coal miners.

Some clinics were initially established to support coal miners.

Zane and I listened to the story of a disabled coal miner. He has COPD related to Black Lung Disease. When he came into the clinic, we weren’t sure that he would even be able to walk back to the room where we could listen to his story. “Weak”, “feeble”, “worthless”….some of the words that came from his mouth as he described his current state of health.

Surprisingly, he loved his work in the coal mines. He felt free, and loved the camaraderie he had with the other men. He was joyful describing some of the tasks he’d done over the years, but had to quit because of the dust. “It was everywhere, and so thick that you couldn’t see the man right in front of you”. It was a dangerous job, but he was able to provide for his family.

Since being put on disability, he hasn’t been able to get an adequate pension from the union. He has a strong support system, but was brought to tears because he saw himself as a burden. He’s had 8 hospitalizations over the past year due to exacerbations of COPD.

At the beginning of the session, he was was struggling to breathe, but what happened at the conclusion of his story left a deep impression on my heart.

He thanked Zane and I for listening to him. “It feels like a weight has been lifted from my chest. Sometimes it’s nice to talk to someone besides close family and friends. I feel like I could run around this room!”.

Holding back the tears, I thanked him for his time, and for sharing some of the barriers he’d had in his life. He left the room with his head and chest held high.

Neither Zane or I provided our coal miner any medications, didn’t make a care plan with complex nursing diagnoses. We just listened. He felt better leaving than when he came, and this defines what nursing can be for the populations we serve.

Jeff, Rachel, Zane and I have more oral histories this afternoon and hope to glean useful information for the providers of Cabin Creek Health System. We want them to hear some of the barriers their patients have for chronic disease maintenance and staying out of the hospital.

Thanks for reading!

Ashleigh @AshEliseMPH #RuralHealth

Collecting Patient Histories: Culturally Sensitive Interviewing

The conclusion of our last post found us busy scheduling interviews with patients in hopes of further understanding – from a culturally sensitive perspective – what barriers exist to our patients’ care.  Since then, after dividing up into teams of two, we have efficiently covered multiple counties in a relatively short amount of time and have collected several stories.

Purposefully, the technique of interviewing introduces neither scripted questioning nor new information, so that the stories gathered remain genuine and unbiased.  The beauty of this process is that the story of the patient interviewed is revealed, layer by layer.  The amount of suffering we have encountered has been tremendous, but it does not eclipse the equally surprising character and resilience of these West Virginians.cheap inflatable water slides for sale

A swinging suspension bridge crossing the river on the way to meet up with a patient and hear their story

A swinging suspension bridge crossing the river on the way to meet up with a patient and hear their story

Each day we continue to attend multiple clinics, shadowing our preceptors in an attempt to understand primary care at its core.  The pace varies, but one student seeing eight patients in the span of two hours is not uncommon for a Mondaychong qi you yong chi.

QUALITY IMPROVEMENT PROJECT STATUS:  At this time, objective data analysis continues but is now (fortunately!) accompanied by a more human dimension as common, underlying themes are teased out of patient stories.  We will report on findings soon as our presentation (presently underway) takes shape, so visit us often! ~ Jeff Lance

A common site in coal country, closed "Company Stores" once required miners to use their earnings - script - to purchase items as they were not paid in US currency

A common site in coal country, closed “Company Stores” once required miners to use their earnings – script – to purchase items as they were not paid in US currency

ABSNs First Days in “The Holler”

We support rural health

We support rural health

What do you get when 8 ABSNs, 6 MSNs, and 1 instructor are packed into a cabin meant for half that amount? The answer is new cabin. We were hardly settled before we began our days in West Virginia, filled with tours of the different hollows/valleys or “hollers” as the residents of Cabin Creek say. These are the areas typically near creeks, where people are able to build communities. We also learned about the impact the coal mining industry and mountain top removal sites have had on this community.

We will never know what was said during this conversation between our tour guide and an employee of a big coal company…

The main clinic in the Cabin Creek community was initially established to support coal miners with Black Lung Disease and their families. Many patients

in both the Cabin Creek Health System and New River Health System, where students are placed, have generations of families that have lived in these communities their whole lives. This is a valuable characteristic for rural West Virginia, because our approach for tackling our quality improvement project relies on oral histories.

The administrative and medical staff have tasked the ABSN “SWAT Team” with discovering the story of patients that have had over 2 hospital admissions over the past 12 months.

Plugged in doing chart reviews

Plugged in doing chart reviews

The admitting conditions are related to Chronic Obstructive Pulmonary Disease, Chronic Heart Failure, Hypertension, Diabetes Mellitus, and others, which are typically managed in the primary care setting.

What are the barriers these patients face with managing their conditions? Statistics can only tell us so much, and we want to take a culturally sensitive approach. We will do this by hearing their stories. We are busy reviewing charts and have interviews set up after clinic/shadow time with our preceptors in the morning.

I will keep you posted. Please visit my twitter account @AshEliseMPH for real time updates with #RuralHealth as the hash tag.

It was a long climb #Don'tJudge

It was a long climb #Don’tJudge

“The meaning emerges from the interaction.” ~ Dr. Dan Doyle

Throughout the past two weeks we have been discovering the meaning within these words that were shared with us one night over dinner with a physician from the New River Health System. “Within the clinical encounter,” Dr. Doyle said,” the meaning emerges from the interaction.” We have been taught a certain approach to patient interaction. When a patient presents to a clinic visit, we poke and prod with questions, seeking specific information. But, even with the intended good will behind our approach, something is still not working. What would happen if we handed over the control? If we stepped out of the driver’s seat and let the patient steer the conversation. What if we let go of our expectations, the drive for answers, and simply listened? William Osler, father of modern medicine, is quoted as saying, “Listen to your patients. Listen and they will tell you what is wrong with them. Listen long enough, and they will even tell you what will make them well.” Maybe what we need is a return to his philosophy; a return to oral history.

During the last few days of our stay in the West Virginian mountains, we put our final touches on the project we had been given to do. I say “our” final touches, because the work we have done is merely the foundation of an approach or tool that the Cabin Creek Health Systems (CCHS) may use to increase the effectiveness of their communication with patients. In the hopes of increasing our understanding of the Oral History approach, we split into pairs and went on home visits throughout the communities surrounding Cabin Creek. Patrick Krueger and I visited three different homes, and came away with three very different experiences. As a group we created this list of “lessons” learned and tips to conducting an effective oral history interview:

  • The goal of the interaction is to establish the relationship and foundation
  • The emphasis should always be listening
  • Learn to be comfortable with silence
  • Digressions do not exist; affirm the  participants’ stories
  • Utilize neutral facial expressions/avoid nodding/verbalizations
  • Avoid the urge to use “teachable moments”; mentally note the statement for later follow-up or motivational interviewing
  • Keep follow-up questions or statements succinct and open
  • Be present; focus on the client
  • Respect time limitations

I would like to emphasize three of these points, one through a story, and two for their poignancy. At the first home Patrick and I visited, we spent 30 minutes listening to this woman share her struggles with diabetes and weight loss. She haltingly shared her story. But, as soon as we thanked her for her time and turned off the recorder, our true education began. In talking about her home and her hobbies, she casually mentioned her frequent use of the tanning bed in her back room. Unable to control my surprise, my mouth fell open. That, of course, raised her defenses, and we ended up doing a little risk-factor education. This was a departure from the true nature of our visit, which was to hear her story, not judge it. Utilizing neutral facial expressions is paramount. When someone is sharing their story, judgmental expressions, such as raised eyebrows, and a jaw dropped in disbelief, can effectively close the book of their lives they had so graciously opened for you to read.

We presented our findings to CCHS as a tool for their Health Coaches to use in forging a strong relationship with their clients. The aim is for the Oral History approach to be utilized on the first visit, in order to lay the foundation for more effective motivational interviewing on subsequent visits. In receiving someone’s oral history, you are being given a window into their lives. It is a beautiful way to come to truly know someone. What a better way to start a therapeutic relationship. But, in order to foster this type of openness, the interviewer needs to avoid the urge to capitalize on any and all “teachable moments.” As nurses, we have been taught to never let a opportunity for education slip by. However, in this setting especially, imparting knowledge or advice through education, however well intended, creates a power differential. So, it is imperative to hold back on those urges. Make mental notes only. And simply continue to listen, opening yourself to truly hearing their story.

Lastly – probably the hardest part of this approach – is silence. Silence is a powerful force. And under its power we saw individuals blossom. By our silence we them gave the gift of time to construct and relive their stories, and we conveyed our genuine interest in their lives. I know I have yet to reach the point where I am comfortable with silence. But, I have seen the beauty that comes out of letting that silence stretch a few moments longer than normal. Fears are confessed, joys are shared, truth emerges.

For two weeks, our team of 7 persevered through long days; hours and hours of commuting on curing country roads between the clinics, the communities, and our beautiful forest cabin. We also spent countless hours researching, conversing, and compiling our plan to present to CCHS. (If you would like to view the fruits of our labor, please visit www.oralhistorytrainingmodule.com ). We also cooked delicious meals every nights, wandered through the forested hills surrounding New River, and even spent an afternoon rafting down its turbulent waters. All in all, I believe that we came away from West Virginia changed. This experience has reshaped the way we will approach communication with our clients; to focus less on searching for the right questions to ask, and more on the relationship built, and the words that are spoken. For it is true – the meaning we are searching for emerges from the interaction we foster with being open.

            

 

The Golden Rule of Primary Care

Throughout the last two weeks, a majority of our mornings have been spent shadowing providers in the various clinics within the Cabin Creek and New River Health Systems. Bettina Hall, one of our group members, described this experience best; “It has been a remarkable experience. Because access to care is limited, providers have to utilize their creative and skilled efforts to offer the best and most appropriate medical care for their clients, many of whom are economically disadvantaged. I think one of the main things that has really stood out to me is the commitment and sincerity providers put into the well-being of all their patients, and its clearly evident that the patients equally value their time, and the support that they receive from the whole medical team.”

Being that we will be starting our master’s program in the fall, and a lot of us are aiming to be primary care providers, these mornings offered an exciting sneek peak into our careers. I was blessed with the opportunity to observe PAs, NPs, and MDs in action – serving their clients with the utmost compassion, perseverance, and creativity. The health care challenges that the Cabin Creek Community faces are complex; rooted in a social history of oppression and isolation. Through what amounted to hours of conversations with providers and medical assistants, nurses and aministrative staff, we discovered that the major health issues in the area were hypertension, diabetes, obesity, and depression. The vast majority of clients I saw were under an opiate contract due to the prescriptions they had for managing their chronic pain. I had conversation upon conversation with providers about how best to manage pain, and how to work with a population in which the percentage of narcotic abuse is tragically high. Both health systems are fighting this battle with perseverance. They are turning to the evidence within the literatire to offer their clients the best care possible, and to help their entire communities break free from the chains of addiction.

This is just one example of the quality of care that these clinics seek to provide. Cabin Creek Health System (CCHS) is constantly addressing the needs of their community in an innovative, honest, and team-centered manner. I was truly inspired by the unparalleled commitment to service that was exhibited by the CCHS staff. John Rice, PA.C is a prime example of this. An article about the outstanding care he give his patients was printed in the Charleston Gazette. One of their patients credited John Rice and CCHS as helping her win the fight against food, and subsequently gain back control of her health. He is committed to the health and well-being of his patients – seeing them as whole human beings worthy of respect and love. And through that he empowers them to take charge of their health and their lives. Bettina, who shadowed him for these two weeks, shared an example of the thoughtfulness and intentionality with which he approaches the relationship with his patients. He is so in-tune with his patients that he picks up the small things; nothing a patient tells him is irrelevant. A patient told him it would be their birthday the day of their appointment. So, John made him a brownie, decorated on a plate that said “Happy Birthday.” Bettina called him “a quintessential good Samaritan.” It is stories like this that truly inspire and encourage me. Providers who are working and living within their communities – serving a whole community. They are completely immersed, committed, and persevering, offering the continuity of care that is needed to effect true and sustainable change.

Happy Birthday Gift

It was in this environment that we got to spend each morning of the past two weeks – deepening our understanding of the culture and the lives of the people, through the eyes of their providers. Dr. Dan Doyle, a committed and passionate physician who has provided over 30 years of service to both the Cabin Creek and New River clinics, penned a Golden Rule of Primary Care, which is hanging in most of the clinics buildings. I will leave you with his words, and please stay tuned for more of our journey, and how we used what we learned in the clinics, combined with our oral history training, to create a plan for effective patient communication.

Dr. Dan Doyle’s Golden Rule of Primary Care

 

“Through the telling of what they know, people figure out what they think.” ~ Michael Kline

West Virginia Bound

In a Dodge minivan, every nook and cranny packed, our seven member team departed from Atlanta early Sunday morning, bound for the tree-covered mountains of West Virginia. We knew little of what to expect over the next two weeks as we watched the surroundings transform into rolling hills. We knew only of our destination: Cabin Creek Health Systems (CCHS), a network of rural clinics delivering primary care to the under-served mining communities in the counties outside of Charleston, WV. We are all in our last semester of the Emory ABSN program. After a year of metropolitan hospital clinical experience, we were ready to get a taste of rural primary care – with all of its challenges and surprising rewards. We were also bound together by a mutual curiosity about the culture of these West Virginian mountain communities, which heightened our anticipation for what this experience would hold in store for us.

Patrick, Bettina, Colleen, Hardie, Lora, Lauren, & Shawn Marie

After a warm welcome from the CCHS director, Craig Robinson, his wife Judy, and the CCHS education and program coordinator, Amber Crist, we eagerly listened to the project idea they have outlined for us. As a continuation of their unceasing, and innovative journey to improve the quality of their patient care, they organized a two-day orientation and training to introduce us to the richness of the local culture, and to acquaint our team with a methodology of obtaining oral histories. The idea behind this training is to equip us with an effective tool with which to untangle the complex web that characterizes the health of these communities.

Our arrival at the CCHS administrative offices early Monday morning was greeted by the gentle strumming of a pair of guitars as voices rose in the wholesome harmony of Appalachian ballads. That was the opening to our immersion into the local culture, seeing for ourselves the environmental and social impact that strip and deep mining have had on this area.

Mountain Top Removal Site

The true cost of coal

Within a culture that values land as their identity and their heritage, a seemingly incurable pain comes out when family land is taken or destroyed. A majority of this population struggles with what Amber calls the West Virginia Quad – hypertension, hyperlipidemia, obesity, and diabetes. Dr. Westfall, a family practice physician who serves with CCHS, added two more co-morbidities to the group – pain and depression. The harsh and violent reign of coal mining has left its mark upon the hearts of both the mountains and the families who have called them home for generations upon generations. Dr Westfall offered a new perspective when I asked about her most rewarding experience in working with these community individuals. She paused for a few moments, deep in thought. “It is hard to pick one out,” she said. “Being with the people. Seeing their strength and resilience. I may not see the good outcomes, but I do see their strength. And I get to sit with them through it.”

The harmony of Appalachian ballads

Michael and Carrie Kline, a couple who have dedicated their lives to listening to the stories of Appalachian miners and giving the voiceless a voice, lead us through a condensed training in eliciting an oral history. Theirs is a specific methodology that transfers the power of the telling to the teller. It is not driven by questions, but by the power of merely listening. For two days we wrestled through this possible new approach to obtaining a health history; an approach that places the patient truly at the center, enables the listener to see the individual within their own social context, and to hopefully elicit goals, values, and knowledge without the prodding interrogative questions. This afternoon, at the end these two long days, volunteers from the community came to be interviewed. We practiced the skills we had learned, framing the interview as a time to talk about their life and community health. We opened with the statement “Tell me about your people and where you were raised.” At the end, when we were collecting our thoughts, we all realized that we have a lot of work cut out for us over the next two weeks, working through this new technique and discerning how this could possibly be used within the CCHS patient care. Stay tuned as we discover what happens to an individual and a community when they share their story, and what that can mean to their health and well-being.