Providing consumer health information in the rural setting: Planetree Health Resource Center's approach

Abstract

Both lifestyle and geography make the delivery of consumer health information in the rural setting unique. The Planetree Health Resource Center in The Dalles, Oregon, has served the public in a rural setting for the past eight years. It is a community-based consumer health library, affiliated with a small rural hospital, Mid-Columbia Medical Center. One task of providing consumer health information in rural environments is to be in relationship with individuals in the community. Integration into community life is very important for credibility and sustainability. The resource center takes a proactive approach and employs several different outreach efforts to deepen its relationship with community members. It also works hard to foster partnerships for improved health information delivery with other community organizations, including area schools. This paper describes Planetree Health Resource Center's approach to rural outreach.

The Dalles is located in north-central Oregon along the Columbia River, about eighty-two miles east of Portland. It has the historic distinction of being called the “Point of Decision” on the Oregon Trail. Early pioneers making it to The Dalles had to decide whether to risk life and limb rafting down the Columbia River or to take the treacherous overland route across the Cascade Mountains to reach their coveted dream of the rich, fertile valleys at the end of the Oregon Trail. Today, The Dalles sits in the congressionally mandated Columbia River Gorge National Scenic Area.

The citizens of The Dalles enjoy many natural wonders—mountains, rivers, waterfalls, deep gorges, and basalt rock formations. This same natural beauty isolates the community from the fast pace of Portland's big city life to the west. The interstate highway, which winds its way along the river to Portland, is a beautiful drive, except for the bitter winter months when the geography of the mountains makes this road a dangerous venture. There is a vast expanse of farmland and arid rangeland that extends to the east and the south for over a hundred miles. Wasco County, where The Dalles is located, comprises 2,396 square miles and 22,500 people. The primary industry is agriculture with cherry, apricot, pear, and apple orchards; vineyards, berry farms, and wheat ranches dot the landscape. Other industry includes aluminum manufacturing, hydroelectric power, tourism, and health care.

Health care in the Columbia River Gorge spans two states and encompasses four small, rural hospitals—two on the Oregon side of the Columbia River and two on the Washington side. Mid-Columbia Medical Center (MCMC) in The Dalles is the largest, with forty-six inpatient hospital beds. MCMC boasts a broad physician roster: eight family practice physicians and thirty-three medical and surgical specialists. The local staff is complemented by a multidisciplinary group of physicians who hold weekly specialty clinics at MCMC in the areas of cardiology, oncology, dermatology, allergy, gastroenterology, neurosurgery, and plastic surgery. These specialty physicians live in the Portland metropolitan area and drive up to two hours to The Dalles once or twice a month to see patients; hence, they are called “visiting physicians.”

The vastness of the region requires that people needing health care be willing to drive. Approximately 62,500 people live in MCMC's primary service area, a sixty-mile radius, encompassing 5,668 square miles in four counties across two states. It can be an hour's drive to have a routine medical check-up. This same hour-long drive can be an eternity for a mother in labor or a wheat rancher who has suffered a stroke.

“Thank you so much for all your help in my family's time of need. The information you helped me obtain was extremely helpful in making some very important life decisions. We'll always be grateful to you and the Planetree Library Resources.” Planetree Health Resource Center comment book

RURAL PROFILE

There is a sense of independence and a “can-do” attitude among people who choose to make this area their home. Recruiting physicians is difficult; therefore, doctors are viewed both as respected professionals and welcome neighbors. Locally, an aging population requires more and more adult family members to become caregivers for parents at the same time they are raising their own children. Home care and foster care are very popular. There is much curiosity about complementary care and a real desire, especially among middle-aged and older adults and those with chronic illnesses, to learn more about self-care.

The Dalles is rich in health resources for a community its size. In addition to its comprehensive medical center and diverse medical practitioners, the city has an active county health department; two nursing homes; a state veterans' home; four assisted-living facilities; social services for the aged, the disabled, children and families, mental health patients, and victims of domestic violence; hospice care; durable medical equipment suppliers; and school nurses. Support groups exist for many conditions such as cancer, stroke, diabetes, Alzheimer's disease, and fibromyalgia.

Information resources include a recently renovated public library, a new community college library, grade school and high school libraries, and the Planetree Health Resource Center, a consumer health library. GorgeLINK, a resource-sharing network that links the library collections in a three-county area of the Columbia River Gorge, including Wasco County, is a vital information connection. Individuals in remote communities, whose libraries are GorgeLINK members, may search the database and check out materials for delivery through a shared courier system. Residents also enjoy Internet connectivity through several local Internet service providers. In this context, the Planetree Health Resource Center serves the public and health professionals in The Dalles and surrounding communities.

Planetree sprang from a grassroots movement started by Angela Theriot, who endured an unpleasant hospital stay at a major United States medical center. After her hospitalization, Theriot organized a group of physicians, nurses, civic leaders, and interested citizens in the San Francisco Bay area to form Planetree, adopting as its mission the goal of changing the way health care was delivered in America. Planetree established a three-pronged approach of humanizing, personalizing, and demystifying the delivery of health care. Mid-Columbia Medical Center's chief executive officer (CEO) and several MCMC Board members heard a Planetree executive speak about this model of health care delivery at a conference in the late 1980s. The speaker challenged a hospital in the audience to fully incorporate the Planetree model of care. MCMC's CEO and Board pursued this challenge and, in 1990, MCMC became the first hospital in the United States to adopt the Planetree model facility-wide.

MCMC leadership was very committed to the information-access component of demystifying health care. The CEO truly wanted a consumer health library to serve all of the people in the rural region, not just the patients and families of MCMC. The CEO and hospital board had the foresight to locate the Planetree Health Resource Center in the downtown corridor of town, rather than in the hospital lobby or another part of the hospital, the more typical approach. It was felt non-patients might find it intimidating to use the Resource Center, if they had to visit Mid-Columbia Medical Center.

“I want to say thank you to Planetree. It has helped me find out more about AIDS and HIV, so I don't look into my future with as much terror as I might have without this information.” Planetree Health Resource Center comment book

THE RESOURCE CENTER'S MISSION

Planetree Health Resource Center's mission is to help demystify the health care experience by providing a comfortable, confidential, and trusted place for consumers, patients, family, and the general public to research and explore health-information needs. Because of its rural setting, the resource center also serves area health professionals. Administratively, the resource center functions as a department of Mid-Columbia Medical Center. Both the medical center and Mid-Columbia Health Foundation provide funding. The resource center's community-based location has been an asset and has enabled it to become truly integrated into the rural communities it serves.

The Planetree Health Resource Center opened June 2, 1992, on the first floor of a remodeled Victorian home, occupying 1,360 square feet. The current collection consists of 2,500 books, 350 audio-visual programs, sixty-five magazine subscriptions, four public Internet stations, and two GorgeLINK terminals. Because the home dates from the 1870s, many individuals visited initially out of curiosity and pride in the rehabilitation, not to browse the library collection! The original staff consisted of a full-time director, who had a master's degree in library science, and a full-time library assistant, who was college educated. A half-time staff person, who had a college degree, was added in June 1997.

Early outreach efforts involved presenting a community health lecture series, connecting to educators, participating in the hospital's annual health fair, hosting support group meetings, and public speaking to area community groups and businesses. All of these outreach efforts continue today.

Staff felt early on that they needed to reach out to the community and make the resource center's services and themselves known. When the resource center opened, there was apprehension regarding its mission and purpose. Were the staff working with the medical community or offering an alternative—code for, “will my physician be upset with me if he or she knows I've visited the Planetree Health Resource Center?” Remember that these were the early days of direct consumer health information delivery. The Planetree Health Resource Center was, and remains, one of the few community-based centers. Fortunately, the staff had garnered as much support as possible within the medical community before the grand opening, by meeting with different physician groups and offering the resource center's services as an aid to physician practice—both in terms of their own information needs and the needs of their patients.

Rather than wait for the public to come in, the staff reached out to them by developing a slide show for talks and presentations to local service clubs, businesses, health organizations and agencies, and support groups. The staff always brought material to give away like bookmarks, magnets, and sample packets of information on a chosen medical topic. After every speaking engagement, someone invariably came forward, asking to keep the packets for use by a family member. The groups were always amazed at the wealth of information in the sample packets. The speaking engagements were meant to clarify the resource center's mission and enable staff to sow the seeds of professionalism and credibility with members of local communities.

The resource center's connection to educators began with early outreach efforts to area school district administrators. Staff invited them for a special tour to show them what the resource center had to offer their faculty. The staff felt very strongly that teachers would benefit from using Planetree resources to understand better the needs of students with health problems. Use of such resources might help teachers adapt their classroom environment, their expectations, or their teaching methods to serve these students better. As a result of this outreach, a tour of the Planetree Health Resource Center became a required inservice for The Dalles district teachers in the fall of 1993. To this day, the resource center enjoys continuing success in partnering with area schools. The high school and community college often hold prearranged special classes in the resource center, so their students may be introduced to and use the collection. Grade school students come for field trips. Resource center staff talk with them about self-advocacy and the importance of being informed health care consumers.

In the fall of 1999, The Dalles School District 12 invited the Planetree Health Resource Center to participate in a Teacher Fair, at which teacher attendance was required. The focus was to help connect teachers with community resources that might better help them meet their students' needs. The Teacher Fair was planned as an annual event. The resource center staff has been pleased that its relationship with the schools continues to grow and strengthen with the passage of time.

A health lecture series was another early outreach effort. The resource center continues to hold the lecture series twice a year, in fall and spring. It runs on consecutive Tuesday evenings, generally for five to six weeks. Each week, a health care provider prepares a community presentation on a timely health topic. All speakers donate their time as a public service. However, given the geography and the weather, the resource center provides a hotel room for guest speakers from Portland or more distant points. The lecture series is an interactive forum—a chance for the public to interact with health care providers in an informal setting. Planetree tries to foster communication in the patient and health care provider relationship, and the lecture series gives people the opportunity to hear important medical information and to ask questions or exchange ideas. There is a strict hour-and-a-half time limit, so speakers are not overwhelmed.

Because the lecture series began in the community room of the resource center, it served as a wonderful point of introduction to the consumer health library. Many first-time visitors were pleasantly surprised with the available resources. Due to the success of the lecture series and the seating limitations of the resource center, its location was changed to a large conference room on the medical center campus in the fall of 1999. The lecture topics have included both traditional medicine and complementary therapies; one week there might be a lecture on managing diabetes on a budget and the next week a lecture on using acupressure for self-care. One common feature has been that all speakers are licensed practitioners. Each attendee has received a list of sample resources and appropriate Websites for each lecture topic, prepared by resource center staff.

“Interesting lecture. I would like additional information on how we as parents can help our children more.” Comment on Planetree Health Resource Center lecture series evaluation form

ANNUAL HEALTH FAIR

The Health Fair is an annual event in The Dalles and is sponsored by Mid-Columbia Medical Center with broad community support. It is part of the Northwest Cherry Festival celebration held on the last Saturday of April each year. It is a traditional health fair, with many booths and interactive stations and much entertainment. After the second year of the resource center's participation in the Health Fair, the center's director suggested to the planning committee that the event be moved from the city's dilapidated civic auditorium to the resource center, making the center an anchor site. The committee agreed. To have enough space to hold the health fair in its new location, the planning committee partnered with two neighboring banks. Each year, the banks have graciously donated their lobbies and a few conference rooms for health fair stations. The flavor of the fair has gained a street fair atmosphere, with a large tent set up outside the resource center and activities at the street intersection connecting the two banks and resource center.

The resource center's staff offers something special for the annual Health Fair. Most recently, the fair included mini-sessions on surfing the Internet for health information; handouts contained a current list of recommended health Websites, arranged by subject. In the past, the resource center showcased speakers, who gave short, fifteen-minute health lectures at scheduled times throughout the day. One year, staffers performed Cancernet PDQ searches for the public and distributed cancer-related materials during the Health Fair. The Health Fair allowed the resource center to further its mission by providing a special day to interact with the public in the context of a broad array of health services and providers.

As part of the initial and ongoing outreach efforts, staff contacted area support groups and invited them to have annual meetings at the resource center. Many groups continue to accept this offer. During their meetings, the groups receive a tour of the resource center, and materials of special interest to each group are highlighted. Handouts on pertinent topics are distributed.

The focus of early outreach efforts was to make the resource center staff known as health information providers and to gain the trust and confidence of area residents. Most of these early outreach efforts were inexpensive, with the largest expense being staff time. Initial outreach efforts established a solid foundation for present endeavors and future plans. The resource center has now been asked to partner with other organizations' outreach efforts. For example, the Wasco-Sherman County Public Health Department approached the Planetree Health Resource Center two years ago and requested that it partner in their Tobacco Education and Prevention Coalition (TEPCO) project. Funding for this program came from an Oregon voter mandate, approved in November 1996 (Ballot Measure 44), which increased the tax on tobacco products. Ten percent of the new tax supported three different programs, one of which was the creation of community coalitions in each county to effect change in how the communities view tobacco, with the ultimate goal of developing smoke-free communities.

One goal of the local TEPCO effort was to build a centralized collection of tobacco-related educational materials for use by both area teachers and members of the general public. Because the resource center is highly visible in its geographic area and known as a place to go for reliable health information, TEPCO felt it could achieve its goal through a partnership. The coordinator of TEPCO approached the resource center to serve as a centralized clearinghouse for any materials purchased with TEPCO dollars. The area schools were also asked to house their tobacco teaching materials in the centralized collection. Through this project, all of the teaching materials, kits, models, books, audio-visuals, and smoking-cessation materials have been cataloged as a special collection and entered into the regional resource-sharing database, GorgeLINK, by resource center staff. Technically, all materials purchased with TEPCO funds remain the property of TEPCO and are officially “on loan” to the Planetree Health Resource Center. This arrangement satisfies the governance of the Public Health Department and MCMC's status as a not-for-profit hospital. TEPCO was asked to supply the resource center with additional bookcases for this project, which it did. The bookcases also remain the official property of TEPCO. In the Tobacco Prevention and Education Coalition advertisements, news coverage, and community events, the resource center is publicized as a partner. Other TEPCO partners are Columbia Gorge Community College, Chenowith School District 9, The Dalles School District 12, and the Educational Service District for Wasco, Hood River, and Sherman Counties.

As a result of its participation in TEPCO, the resource center has recently been approached by two other community organizations. The resource center is negotiating with both the Wasco County Commission on Children and Families and the Mid-Columbia Council of Governments Senior and Disabled Services to act as a clearinghouse for special collections on violence prevention and disability resources, respectively. The resource center enjoys the faith of the local community as a focal point for collecting and disseminating health information.

“Wonderful addition to our community … this is a resource we needed.” Planetree Health Resource Center comment book

PATIENT INFORMATION PACKETS

Another major area for outreach concerned the delivery of health information packets to Mid-Columbia Medical Center inpatients. This service was originally performed by a nurse, who visited hospital inpatients on the acute care medical floors three days per week, asking patients if they had any questions or information needs regarding diagnosis and treatment options or healthful lifestyle changes. Using the resource center's collection, the nurse then put together a packet of information addressing these issues for the patient.

When the nurse left the area, the resource center proposed to offer this service directly. Resource center staff met with nursing administration to seek input. As a result, a nurse still visits patients and gathers their information requests. This nurse then acts as a liaison with resource center staff, who actually assemble the information packets. Currently, when the nurse assigned to visit patients, is ill, or on vacation, resource center staff provide this service. Redesign of the patient information packet service has resulted in a cost savings for the hospital, as resource center staff are highly trained in health information resources and retrieval and can assemble the packets more efficiently. Use of postcards included in each packet for feedback is increasing and so, too, are positive comments. These comments are shared with MCMC administration on a monthly basis, to keep them informed of the service's progress. Interestingly enough, when resource center staff visit patients, the number of information packets requested goes up. Perhaps this is because nurses perform multiple tasks at the patient's bedside, while the resource center staff member's sole purpose is to focus on the patient's information needs. Resource center staff have the necessary time to discuss information needs and resources in depth with patients, and patients respond to this.

The information packets may be brief or comprehensive—covering anatomy, diagnosis, treatment options, coping, and lifestyle information; Websites, local support groups; and books of interest. While producing the packets is labor intensive, MCMC's administration is committed to serving its patients' long-term best interests by providing them with the tools to make sense of their illnesses, communicate effectively with their health care providers, and encourage self-change for better health.

The patient information packet service has continued to grow and evolve as well. In January 1999, at the request of MCMC staff who participated in a hospital-wide care givers' retreat, service for patient information packets was offered to same-day-surgery patients (surgical outpatients) and visiting-home-health patients. Resource center staff modified the information service to these patients by preparing a brief intake and request form that the nurses shared with each patient. The completed forms are picked up by resource center staff three times per week. Rather than supplying a choice of brief or comprehensive information packets, these patients all receive two or three items germane to their identified information need, with the invitation to visit the resource center if more information is needed.

My information packet “told me more about what's happening and going on with me, and explained things that I could understand.” Comment on postcard used for patient information packet feedback

“TO YOUR HEALTH”

In November 1998, the resource center director began to write a monthly health column for the local newspaper, The Dalles Chronicle. On the second Tuesday of each month, the column, “To Your Health” is published in The Dalles Chronicle's health section. The newspaper column features timely topics and strives for an interactive or a clip-list format and highlights local health resources. MCMC's administration views the column as a vehicle to address pressing local health problems. To chart significant disease trends in the community, the resource center director researched top MCMC admitting diagnoses, laboratory tests, procedures, top diagnoses of area family practice clinics, and mortality data of the Public Health Department. As a result of this research, recent columns have focused on asthma and chronic obstructive pulmonary disease, tattoos and body piercing, ear infections in children, and heart health. The Dalles Chronicle is the only daily newspaper in this geographic region and is widely read, giving the resource center significant exposure and furthering its mission of providing credible health information to rural residents.

Another valuable form of outreach is the resource center's fledgling Website.* Since its inception, resource center staff have carefully developed and maintained a support-group database. This database of local, regional, and national agencies and organizations includes contact information and a synopsis about the services the organization provides. In the fall of 1999, after working closely with MCMC's information systems department, the task of uploading the support group information onto the Website as a searchable database was completed, and hot links to support groups were added. Plans for other searchable databases include adding full-text health information in the form of fact sheets about different medical conditions or illnesses, as well as tests and procedures. The Web works without boundaries and by increasing its Web-based services, the resource center will benefit users in remote areas. Information about the semi-annual health lecture series—such as date, time, speaker, and synopses of topics—is also available on the Website. Interested individuals may register through an email link, saving them a long-distance phone call or drive.

“Thank you ever so much for your quick response to our need for information … Our daughter's illness was a serious reminder of the frailty of life and the power of prayer and medicine.” Planetree Health Resource Center comment book

PLANETREE BRANCHES OUT

Perhaps the resource center's biggest outreach effort is a branch library the center opened in neighboring Hood River in December 1999. Hood River County is twenty miles west of The Dalles and is home to 19,000 residents in a 533-square-mile area. Agriculture (principally apples and pears) is the primary industry, together with tourism in the form of outdoor recreation (e.g., sailboarding, skiing, snowboarding, and fishing). The branch library has been built in a vacated room of an ambulatory care clinic, owned and operated by MCMC. The clinic, called Care Corner Clinic, is home to physicians who specialize in family practice, obstetrics and gynecology, and orthopedic surgery. The clinic staff also includes a licensed acupuncturist. The branch library is modest, 563 square feet of public space. It has been designed to hold a small print collection (500 volumes) and a small journal collection (eighteen titles). The focal points of information access are five networked computers with wireless connections to the Internet. The computers also have the capability to run CD-ROM programs. A station may be added to serve as a fixed CD-ROM station, if need arises. The library is wired for an additional two workstations, for a maximum of seven public terminals.

Participation in GorgeLINK, the resource-sharing database, makes branch library materials available throughout the vast service area. In addition, branch library users may search and borrow from the range of materials in GorgeLINK, particularly those health resources of the main Planetree Health Resource Center.

The branch library was intended to provide an additional point of service for individuals seeking health information who were on the west end of MCMC's primary service area. At the January 1999 MCMC Board meeting, a business plan for the branch library was presented. The board approved the proposal for adding a Planetree Health Resource Center branch library at its February meeting with the goal of enhancing MCMC services to its patients at the Care Corner Clinic by providing access to information. In laying the groundwork for this project, the resource center director met with the staff of the Care Corner Clinic to present the project proposal and to seek input to develop clinic ownership of the project. The resource center director also met with the director of the Hood River County Public Library to present the project and to seek support. Working together on GorgeLINK has already fostered a collaborative relationship among librarians in the area, so the project was met with enthusiasm.

Outreach to the local community began as soon as the MCMC Board approved the plan. In March 1999, a mini-version (three lectures) of the Planetree Health Resource Center lecture series opened in the Care Corner Clinic community education room, and a full lecture series began in the fall of 1999. At the beginning of each lecture, an announcement described the Planetree Health Resource Center branch coming to the Care Corner Clinic. Resource center staff met with much positive response to this news. In addition, preliminary news stories generated interest in the new location.

The MCMC Board approved a total budget of $88,439 for infrastructure, equipment, and remodeling of the Care Corner Clinic space for the Planetree Health Resource Center. The project came in significantly under budget, with actual costs about $74,085. The branch library's approved operating budget for Fiscal Year 2000 (calendar year cycle) was $71,235, which included a staff of 1.5 full-time equivalents.

As this project takes root and begins to grow, yet another branch library is anticipated. In April 1999, the MCMC Board appropriated funds to construct a new oncology center on the main MCMC campus. The oncology center will feature a radiation oncology program, in addition to chemotherapy and other modalities, integrated with a whole-person approach to the illness of cancer. Currently, cancer patients in central Oregon must drive at least eighty-two miles to Portland to receive radiation treatment. Radiation treatments are generally given daily for a period of four to eight weeks, depending upon the specific diagnosis. Cancer patients living on the eastern edge of MCMC's service area must drive three hours each way for radiation treatment. Thus, the new oncology center will dramatically benefit cancer patients in this rural environment. Plans for the oncology center include a cancer resource center, which will be an additional branch of the Planetree Health Resource Center. Resource center staff have begun to benchmark cancer libraries and educational centers for this important project. The staff is excited about having an additional point of service to offer knowledge-based resources to patients and their family members on what is often a difficult and frightening journey. An opening date of early 2001 is anticipated.

“God bless you for saving my sanity today. In trying to help in making decisions about my brother's battle with lung cancer, I have been near the edge of despair.” Planetree Health Resource Center comment book

PLANETREE'S COMMUNITY CONNECTION

There are many challenges and benefits to providing consumer health information in a rural setting. While some difficulties of distance and geography are being met by new information technologies, having a personal identity and being in relationship with one another is still important in small communities. This very sense of connectedness draws individuals and keeps them living in rural communities. Consumer health information is very much needed and valued by rural Americans, as evidenced by the strong financial support the Planetree Health Resource Center enjoys and its growth as an integral part of the Columbia River Gorge community. Through the resource center's outreach efforts, the staff have come to know and to be known by the local communities. The resource center's success is measured by the 22,304 visits in eight years of service, by continued funding of the resource center by the MCMC Board, and by the significant endowment fund developed by the Mid-Columbia Health Foundation for the Planetree Health Resource Center. However, nothing speaks more eloquently of the resource center's success than its users, who have made the following comments in notes of thanks.

“Thank you so much for this facility. I learned a great deal about the problem. Now I feel better just knowing.”

“Since my mom was just diagnosed with MS (multiple sclerosis), we came to read about it. Now I know we came to the right place.”

“I can right to good [sic], but I thank you for your help and information. Thank you.”

Planetree Health Resource Center and its branch library play important roles in the rural communities they serve. These libraries pursue their mission of health information delivery as a serious responsibility coupled with great joy and excitement about the future.