Burning Too Many in McCreary

James Corder

Frontier School Of Midwifery and Family Nursing

About McCreary

The county wide population 18,199, seventy six percent are over the age of 18— similar to U.S. average of seventy five.

Access to McCreary U.S Hwy 27 and KY 92.

About McCreary County

McCreary is best known for natural attractions i.e. the Big South Fork National Park, and Cumberland Falls.

County Demographics Average family size in McCreary is 3.0—U.S. average of 3.20

(U.S. Census Bureau, 2009)

Unemployment rate is 14.3 percent, U.S average is 9.8 (U.S Census Bureau, 2010).

Individual poverty rate is 37.3 percent, compared to a U.S average of 13.5 percent (U.S Census Bureau, 2009).

Child poverty in McCreary is 51%, compared to U.S average of 11% (County Health Rankings, Fact Sheet, 2011)

The median home price is $64,100, compared to a U.S median price of $185,400 (U.S Census Bureau, 2009).

Access to Care McCreary County has five small family practices, four of

which employ FNPs. The community has no specialist such as cardiology, women’s

health or pediatricians.

McCreary does not have a hospital or urgent care facility.

Clients commute approximately 30 miles to neighboring county hospitals, and specialist

McCreary Primary Care Center

My community health observation site located on US highway 27 in Whitley City.

The clinic is relatively new, and has been in operation about 6

years.

My Preceptor My preceptor is Donna Campbell MSN FNP. She graduated from

Eastern Kentucky University in 2004. She is the Somerset Regional Director, for the Kentucky Coalition

of Nurse Practitioners and Nurse Midwives.

She is the senior practitioner of four who practice at the facility.

Donna and each of her coworkers have their individual clientele, and see new patients alternately.

Insurance Coverage Medicaid is the largest payer in McCreary @ 46%, Medicare

is responsible for 31% (Kentucky Health Facts, 2009).

The largest insurers are Anthem and United Health totaling approximately 6%

17% of McCreary’ population are uninsured (Kentucky Health Facts, 2009).

All patients are seen regardless of their ability to pay (D. Campbell, personal communication, January 18, 2011)

Health Assessment During my clinical observation many clients smelled

of smoke—which prompted me to search statistics of heart disease, cancer and stroke.

McCreary has the highest crude rate of malignant

neoplasm in the Lake Cumberland Health District. The county is among the three highest in the state at

284.1/100,000 (Kentucky Health facts, 2008).

This number includes all cancers i.e. the skin, colon, liver, or pancreas. So what specifically raised our rates?

Respiratory Neoplasm

Melignant Neoplasm: Trachea, Bronchus, and Lung/100,000

0

20

40

60

80

100

120

140

160

U.S. 55

Kentucky 80.1

McCreary 150.8

• (Kentucky Health facts, 2008)

Smoking Population

Series10

5

10

15

20

25

30

35

40

45

National Benchmark 15%

Kentucky Adults 28%

McCreary High School Studerts 31%

McCreary Adults 40%

(County Health Rankings, Fact Sheet, 2011)

Healthy People Tobacco use is one of the ten leading health indicators of

Healthy People 2010, and is considered a major concern in the United States (Healthy People 2010).

Healthy People Objectives: Implement policies to reduce tobacco use among youths

and adults

Adopt policies, and strategies to increase access to affordable use of cessation treatments and services.

Establish policies that reduce illegal sales to minors, increase cost, and reduce exposure to second hand smoke (Healthy People 2010).

Evidence Tobacco is the largest cause of disease and death in America and

is responsible for over 435,000 deaths every year (Fiore, Jean, Baker, et al. 2009, p. 2).

Smoking is a major risk factor for chronic lung disease, cancer, heart disease and stroke. (Healthy People 2010, p. 30).

Presents risk during pregnancy of premature delivery, miscarriages, and SIDS (Healthy People 2010, p. 30).

Second hand smoke leads to increased risk of heart disease,

asthma, lung disease and bronchitis in children.

There are approximately 3,000 lung cancer deaths each year from second hand smoke (Healthy people 2010, p. 30).

Evidence Continued Tobacco smoke is the most preventable cause of cancer

(McCance 2010, p. 401).

Tobacco smoke is directly related to cancer of the lung, and has historically risen and fallen parallel with the prevalence of smoking (McCance 2010, p. 401).

There are more deaths annually from smoking than from alcohol, heroin, cocaine, homicide, suicide, fires, Motor vehicle accidents, and aids combined (Healthy People 2010, p. 30).

Carcinogens

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Smoke from the burning end of a pipe, cigar, cigarette or exhaled air contains more than 50 known carcinogen (McCance,2010).

Community Diagnosis There is an increase risk of death and disease—

particularly lung cancer, among McCreary’s tobacco users, their families, friends, and coworkers. related to cigarette smoking, as demonstrated by elevated crude rates of malignant neoplasm's of the lungs, an elevated adult smoking population (County Health Rankings, Fact Sheet, 2011), and a large number of patients being treated for respiratory problems (D. Campbell, personal communication, January 18, 2011).

MAP-IT/Mobilize Mobilize: 1st, show the clinic a need to decrease the amount of

lung cancer in the community.

Key individuals needed to implement and track an intervention.

Office manager- to recognize a need for intervention Preceptor- agree to implement the material Other clinicians- to use materials Receptionist- needed to give out material, monitor

supplies.

MAP-IT/Assessment Weakness:

Lack of local support groups.

Lack of access to personalized information on the local level.

Lack of smoking education.

Elevated lung cancer (Kentucky Department of Vital Statistics, 2005)

An elevated adult and high school smoking population (County Health Rankings, Fact Sheet, 2011)

MAP-IT/Assessment

Strengths: Local Health department offers a 3-5 minute

counseling intervention for those who want to quit. Kentucky’s Tobacco Quit Line: a free statewide

telephone-based tobacco cessation resource 1-800-QUIT NOW

Offers one-on-one proactive counseling Smokers may receive up to five scheduled call backs Support one another on line, share stories, and post

daily journal. http://chfs.ky.gov/news/Quitter.htm

MAP-IT/Plan My Proposal Plan: Develop a tool to screen and encourage smoking cessation

The plan of action consists of designing and implementing a booklet of demographic information tailored specifically for McCreary County

The booklet is to be given at sign in to patients who answer yes to smoking on the sign in sheet.

The booklet is intended to prompt the patient to ask the

practitioner for help with tobacco cessation.

The practitioner may then choose to refer to the 5 A’s and clinicians guide for treatment.

Plan ContinuedWhat is the 5 A,s? The 5A’s, Ask Advise, Assess, Assist, and Arrange follow-up is a tool

used to assess clients desire to quit, and directs the practitioner to an appropriate response.

Can be found in, "Treating Tobacco Use and Dependence, Quick Reference Guide for Clinicians (Fiore, Jean, Baker, et al. 2009).”

Recommended by: United States Department of Health and Human

Services. http://www.ahrq.gov/clinic/tobacco/tobarqrg.htm

Systematically guides the practitioner in treating tobacco dependence regardless of how the patient responds to the 5A’s (Fiore, Jean, Baker, et al. 2009).

Scheduled a date to discuss and get approval from preceptor by 050511.and submit proposal for the intervention to faculty by 051011.

MAP-IT• Implement: Once the plan was approved, I set the strategy into action.

Contacted my preceptor to let her know that I had an accepted intervention, and scheduled a date and time.

Explained the intervention to key staff at the clinic.

Actively assisted in the beginning hours of implementation.

Explained the need to call for the first few days to monitor utilization of the plan, and materials.

GoalsShort-term goal: Increase the number of patients who ask for help or

make a verbal commitment to quit smoking by 2 patients per week.

Long-term goal: Focuses on decreasing the number of adults in the

practice who smoke by 10% in the first year,

MAP-It Track Short-Term: Check responses weekly. Track progress by use of a questionnaire. Analyze all data collected Compare data to stated short term goals Document findings, and Inform colleagues of progress

Track Long-term: long term goal will be evaluated by office staff in one

year by chart review.

Track: QuestionnairePlease circle the number that best describes your feelings about the booklet

1. Was the booklet easy to understand? 1 2 3 4 5  2. Did you find the information interesting and educational? 1 2 3 4 5 3. Did you learn anything new about your community? 1 2 3 4 5 4. Did the information cause you to want to quit smoking? 1 2 3 4 5 5. Are you going to attempt to quit? Yes No 6. Did the booklet have an impact on your decision to quit? 1 2 3 4 5 7. May we call you in a few weeks to see how you are progressing? Yes No  Signature-------------------------------------- Phone Number-------------------- Please give this sheet to your provider, receptionist, or put it in the drop box.

Evaluation• 2 week period:• 14 booklets, 5 returned, 1quit attempt• 100% found the booklet easy to read,• 100% thought it was educational• 30% want to quit smoking• 20% indicated going to quit• 40% Booklet’s impact on client’s “quit attempt”.

The 10 county Lake Cumberland District Health Department, had a total of 32 people quit smoking in 2009. using Cooper-Clayton, and Fresh Start

References

Healthy people 2020. (2010). Department of Health and Human Services. Retrieved from Healtyy People.Gov: http://healthy people.Gov/2020/about/DOH/about.aspx

Kentucky Depertment of Vital Statistics. (2005). Resident Death from Selected Malignant Neoplasms (Fact Sheet). Retrieved from Kentucky. Gov: Http://chfs.ky.gov/dhp/vital

McCance, K. L. (2010). Cancer epidemiology. In Pathophysiology; the biologic basis for disease in adults and children (6th ed., pp. 396-435). Maryland Heights, Missouri: Mosby, Elsevier.

McCreary county kentucky (Fact Sheet). (2011). Retrieved from County Health Rankings: http://www.countyhealthrankings.org/kentucky/mccreary

The surgeon general report (2006). Retrieved from United States Department of Health and Human Services: www.surgeongeneral.gov/library/tobaccosmoke/report/index.html

United States Bureau of Labor Statistics. (2011). (Fact Sheet). Retrieved from United States Bureau of Labor Stastics: http://bls.gov/lau

United states Department of Health and Human Services. (2009). Treating tobacco use and dependence, quick reference guide for clinicians (Clinicians Guide). Retrieved from United states Department of Health and Human Services: http://www.ahrq.gov/clinic/tobacco/tobarqrg.htm