Category:Outpatient: Difference between revisions

From Guide to YKHC Medical Practices

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Clinic providers not only provide complex primary care, but also function as specialists given that many of our subspecialists are either in Anchorage or a state away. Providers consult via telemedicine, phone or email in order to develop as well implement plan of care for their patients.  
Clinic providers not only provide complex primary care, but also function as specialists given that many of our subspecialists are either in Anchorage or a state away. Providers consult via telemedicine, phone or email in order to develop as well implement plan of care for their patients.  


Pediatric patients make up a significant portion of the population. There is a subset labeled chronic pediatric patients who have medical issues that require frequent monitoring. The pediatrician with subspecialist consultation often follows these patients. They have diseases such as congenital adrenal hyperplasia, seizure disorder, pulmonary bronchiectasis, congenital hypothyroidism, septo-optic dysplasia and other syndromes, which are still undergoing evaluation. At times due to limitations in scheduling any provider available will see them in clinic. It is important to discuss these patients with more knowledgeable providers.  
Pediatric patients make up a significant portion of the population. There is a subset of chronic pediatric patients labeled with a RAVEN CPP banner (next to allergy labels). These patients have complex medical issues that require frequent monitoring. The pediatricians, along with pediatric subspecialty consultation, often follow these patients. They have diseases such as congenital adrenal hyperplasia, seizure disorder, pulmonary bronchiectasis, congenital hypothyroidism, septo-optic dysplasia and other syndromes, which are still undergoing evaluation. At times, pediatric appointments are not available and non pediatric providers may see CPP patients in clinic. It is important to consult with a pediatric clinic provider (or pediatric hospitalist provider if no pediatrician in clinic is available) if the patient has any complex issues that need addressing.  


Overall we strive to create a medical home for all our patients both near and far. Through the help of departments such as physical therapy, diabetes, tobacco cessation, IMPACT and WIC programs we are able to provide resources to our patients to help them improve and maintain health.  
Overall we strive to create a medical home for all our patients both near and far. Through the help of departments such as physical therapy, diabetes, tobacco cessation, IMPACT and WIC programs we are able to provide resources to our patients to help them improve and maintain health.  
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* Draw a line around the redness of a cellulitis as a way to monitor it.  
* Draw a line around the redness of a cellulitis as a way to monitor it.  
* Don’t treat children under 90 days with Antibiotics – w/o having them come to Bethel for a septic workup.
* Don’t treat children under 90 days with Antibiotics – w/o having them come to Bethel for a septic workup.
'''Refer to the [[:category:YKHC_Guidelines|YKHC Guidelines]] and use them when appropriate for all patients. They lay out specific medical plans based on our populations challenging illnesses/and our resistance patterns.'''
'''Refer to the [[:category:YKHC_Guidelines|YKHC Guidelines]] and use them when appropriate for all patients. They lay out specific medical plans based on our population's challenging illnesses/and our resistance patterns. If you do not follow YKHC guidelines, then you will be expected to document why you are choosing not to follow them. '''
===Clinic Description===
The hospital complex encompasses the inpatient ward, outpatient clinics, surgery and emergency room. There are three outpatient clinics named Delta, Kusko and Yukon that are situated in three hallways adjacent to each other just inside the hospital complex. The three hallways have eight to nine rooms each and a central nursing station. In addition, there are two negative airflow rooms located in Delta and Yukon Clinics.  


===Job Description/Duties===
==Clinic Workflow==
'''8 Hour Shift''': 9 a.m. – 6 p.m. approximately<br />
===Hours===
9 a.m. – 12 p.m. > lunch > (RMT) > 1:20 p.m. – 6 p.m.
Most providers are expected to work Monday through Friday, 8-9 hour days, ~8am-5pm with an hour for lunch. If nursing staffing allows, and with permission from supervisor, some providers may work 4 x10 hour days. Providers are expected to complete all clinical work by day’s end.   Providers are given three ½ days/month for administrative duties, additional if doing village trips.
===Scheduling===
Providers will have extended appointment times during orientation and when working a full schedule, will have 14 x 30 minute appointments/day with 2 overbooks. 1 hour is designated for 1st Pre-natal visits. Clinics are closed for all Federal Holidays (does not impact PTO).
===Nursing===
Providers will normally have a 1:1 nurse to assist with visits. Nurses may, contact Access to Collaborative Treatment or ACT (formerly IMPACT), give acetaminophen or ibuprofen for fevers, administer influenza vaccines, and nebulizers independently. They will propose orders, administer medications ordered by providers, assist with procedures, set up rooms, etc. Providers should meet with nurses before and after shifts to review patients, plan for future labs, provide feedback, etc.
===Patient Clinic Flow===
Patients arrive at YK and first go to registration to check in.  This will change their status in the ambulatory schedule in PowerChart, alerting nursing staff of arrival. Nurses will screen patients and either escort the patient back to waiting area, or ‘rooms’ the patient and informs the provider.
===Nursing Screening===
Nursing staff will check vitals, update social history, assess falls risk, screen for depression and infection, and address immunization needs. Nursing will advise providers if something is abnormal or needs attention.


'''Non RMT Provider 8 Hour Shift''': 9 a.m. – 6 p.m.<br />
===Case Management===
9 a.m. – 12 p.m. > lunch > 1 p.m. – 6 p.m.
Each village has a case manager in Bethel. The case managers work with different patient groups. If you have a complicated patient who needs several appointments set up, or medical equipment, including e.g., ensure, home health services, etc., you should contact the case manager to assist you in caring for the patient.


*Providers are exempt employees and are required to attend required meetings and work until patient care responsibilities are complete. Outpatient Clinic Meetings 8 a.m. on every third Monday and Interdisciplinary Rounds at 8 a.m. on Thursdays are mandatory.
===Patient Travel=== 
Often challenging due to weather. There may be days when no planes (and therefore patients) arrive in the am, and all arrive in the afternoon. When this happens, Bethel patients may be called to come in if possible. Because folks travel far in many cases and often at substantial inconvenience and expense, providers need to do whatever they are able whenever patients are here in Bethel.


Radio Medical Traffic (RMT): Mon-Fri. 10 a.m. – 6 p.m.<br />
===[[Meetings]]===
One practitioner per group will be assigned to do group orphan RMT, assist clinic providers with RMT and help clinic with patient care as able. Continuity and back-up RMT support will be requested from provider staff on admin time first. Practitioners are required to attend regular scheduled meetings.
 
Admin: 9 a.m. – 6 p.m.<br />
Expected to work a regular workday, do continuity RMT, and attend required meetings. As a last resort, may be used as a jeopardy provider or other duties as assigned. Administration time is typically one half day twice per month.
 
Village Admin: Mon-Fri. 9 a.m. – 6 p.m. <br />


This day is given to a provider who has completed a 3 – 5-day village trip to complete charge sheets, charting, referrals and follow-up work. Expected to work a regular workday, do continuity RMT, and attend required meetings. As a last resort, may be used as a jeopardy provider to help with RMT, clinic or other duties as assigned.
===[[Meetings]]===
==Preparing For and Navigating Daily Clinics==
==Preparing For and Navigating Daily Clinics==
First and foremost our clinic does not function like a private practice. Flexibility is key to your success in clinic. The schedule may change many times throughout the day due to travel and Medicaid constraints on patients. In addition, due to limitations in staffing you may have a different nurse day to day. We make every effort to keep the same nurse with the same provider. Below are some reminders to help your transition to outpatient clinics.  
First and foremost our clinic does not function like a private practice. Flexibility is key to your success in clinic. The schedule may change many times throughout the day due to travel and Medicaid constraints on patients. In addition, due to limitations in staffing you may have a different nurse day to day. We make every effort to keep the same nurse with the same provider. Below are some reminders to help your transition to outpatient clinics.  
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'''Weather delays:''' Consider having your nurse call in your Bethel patients to be seen earlier that day for village patients arriving later due to weather. If you have no patients to be seen consider pulling level 4 and 5 patients from the ER. Discuss this with your '''charge nurse as well as ER charge nurse'''. This is best arranged by having the provider communicate directly with the emergency department.  
'''Weather delays:''' Consider having your nurse call in your Bethel patients to be seen earlier that day for village patients arriving later due to weather. If you have no patients to be seen consider pulling level 4 and 5 patients from the ER. Discuss this with your '''charge nurse as well as ER charge nurse'''. This is best arranged by having the provider communicate directly with the emergency department.  


==[[Bethel Regional High School Clinic]]==
==[[Clinic Appointments/Encounters]]==
As a regional medical center, we have limited specialist access in house.  Thus, as general outpatient providers, we evaluate and manage many different chronic and acute medical problems that would usually be seen by a specialist.  With our extensive network of specialists, we are able to coordinate management for these more specialized issues.  Some of these specialties include orthopedics, pediatrics, and women's health.
 
During appointments in outpatient clinics, providers are expected to complete both sick and well visit encounters.  For more specific information about these encounter types, please follow the link in the title above.


==[[Outpatient RAVEN Charting]]==
==[[Outpatient RAVEN Charting]]==
==[[Clinic Appointments/Encounters]]==


==Paging==
==Paging==
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Texts live for 1 day only and then will disappear, so not intended for permanent documentation
Texts live for 1 day only and then will disappear, so not intended for permanent documentation
==[[Pharmacy]]==
==[[Pharmacy]]==
Our pharmacists are a great resource. Always feel free to ask the pharmacists questions.  They are always willing to look up things.   
Our pharmacists are a great resource. Always feel free to ask the pharmacists questions.  They are always willing to look up things.   
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* Phone #: 6377 or 6196
* Phone #: 6377 or 6196


==[[:category:Women's Health|Women's Health]]==
==Medication Refills==
Each clinic does Women’s Health Care as able, including PAP smears, breast exams, IUD and Nexplanon placements/removal, and endometrial biopsies. There are several case managers who help with women’s health.   
Medication refills are part of your daily clinic responsibilities. 
 
Request for refills will arrive in your Message Center in PowerChart/FirstNet.  Our pharmacists have a medication refill protocol that will allow them to refill meds for 6 months if they meet certain criteria, as well as allow them to order labs in your name for your review.  Please review the labs and if able, give 6-11 months of refills. 
 
If a controlled medication is ordered, and the provider has access to the EPCS (Electronically Prescribed Controlled Substances), the process will be paper-less.  Providers without access to EPCS (locums), will need to print the prescription, sign it, and deliver it to pharmacy. 
 
Currently we are rotating C2 refills through outpatient providers with assistance from pharmacy, checking PDMP.  If someone is on vacation, you may be asked to refill medications for patients from their panel.  Please review the patients’ labs and refill them as needed. If they are on a chronic pain agreement, please refill them as well.  Part of our obligation in doing a pain agreement with a patient, is that when that provider is out, someone will fulfill their agreement and refill their pain medications. 
 
At times when doing RMTs with the villages, you may need to order medication refills.  Once you have verified that it is appropriate for them to get the refill, order it in PowerChart/FirstNet by right clicking over the medication.
 
==[[Radiology]]==
We have a completely digital x-ray system, ultrasound, mammogram, and a CT scanner in Bethel.  We do not have an MRI.   


We follow the ASCCP guidelines for dealing with abnormal PAPsThere is a great app for it you can put on your smart phone.  The current YKHC PAP guideline recommends no PAPs under 21 and then q3 years after that until 30.  At 30 years to 65 years of age they need PAPs q5 years as long as there is no history of abnormalities.  We now use liquid PAPs.  If abnormal PAPs, they are followed in a database by the CDC Breast and Cervical Care Manager.  
Our radiologists in Ohio and read all examsOur radiologists are available remotely 24 hours a day and once a month, one of them comes to Bethel to do lower GIs, VCUG’s etc.  


Any abnormal looking cervixes, endometrial biopsies and skin lesion removals in the perineum that you feel need further work up, can be referred to Women’s Health in Bethel.  Feel free to contact the Gynecology Case Manager for that @ 543-6557.
We can send x-rays to ANMC for additional review by specialist such as orthopedics (see ORTHOPEDICS / TELERAD).
Mammograms can begin at age 40, but our current YKHC guideline is to start at age 45 and do them q2 years.  If you have a patient with an abnormal breast exam, send her to Bethel for a mammogram and a breast ultrasound.  Both must be done prior to the surgeon seeing them.  You need to clearly document where the mass is.  If she is under 40, they will only do a sonogram.  If she is over 40, they will do both a sonogram/mammogram.


For all referrals to ANMC surgery, whether to see the general surgeon in Bethel Specialty Clinic and/or a surgeon in ANMC, you will need to have a phone consult with an ANMC surgeon and this should be documented on the specialty referral form.  The [[:category:Women's Health#Women's Health Grant Info|WH Grant]] Case Manager will make sure that copies of the mammogram and sonogram go to ANMC for review prior to the patient’s visit.
Any concerns regarding orthopedic or surgery x-rays should be sent via Telerad for review.


==Procedures==
==Procedures==
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For more details about the process of RMT, urgent RMT, emergency RMT, and different scenarios, please click the title in blue to link to this detailed information.
For more details about the process of RMT, urgent RMT, emergency RMT, and different scenarios, please click the title in blue to link to this detailed information.
==Behavioral Health==
We have a very at risk population for suicide and substance abuse.  We have a very high suicide rate.  We screen for depression on every visit.  If the depression screen is positive during the screening for an outpatient visit in the SRCs, the Wellness Counselor or Behavioral Health clinician in the SRC should be called to see the patient.  Click [[Behavioral Health Services|here]] to see a list of the different resources available in the different parts of the hospital for our patients.


==[[:category:Consults|Consults]]==
==[[:category:Consults|Consults]]==
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For more detailed information, please click the above "Consults" category title to link to a list and description of the provided consulting services.
For more detailed information, please click the above "Consults" category title to link to a list and description of the provided consulting services.
==Clinic Case Management==
Each village has a case manager in Bethel. At this time there are 7 case managers that work with different patient groups. If you have a complicated patient who needs several appts set up, or medical equipment – including ensure etc, or home health services– you need to contact the case manager to assist you in caring for the patient.
* OB/GYN /Centering – Brenda Lamont RN 543-6557
* Obstetrics/Centering – Ann Glasheen WHNP/RN – 543-6305
* Cervical/Breast Management/WH Grant – Nina Jones RN 543-6296
* Aniak and villages –Jean Mute RN 543-6140
* Toksook Bay and villages – Allison Samuelson RN 543-6127
* St. Mary’s and villages – Allison Samuelson RN 543-6127
* Hooper Bay and villages – Robin Lawrence RN 543-6639
* Emmonak and villages – Robin Lawrence RN 543-6639
* Chronic Peds/Synagis – Tammy Alderdice RN 543-6634


==[[Specialty Referrals|Specialty Referrals]]==  
==[[Specialty Referrals|Specialty Referrals]]==  
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Please click [[Specialty Referrals|here]] for more detailed information about individual referral types.
Please click [[Specialty Referrals|here]] for more detailed information about individual referral types.
==[[Bethel Regional High School Clinic]]==


==[[Village Trips]]==
==[[Village Trips]]==


==[[:category:Telemedicine/AFCHAN|Telemedicine]]==
==[[:category:Telemedicine/AFCHAN|Telemedicine]]==
We have a web-based application (AFCHAN) that facilitates long distance consultation by allowing our providers to share media with specialists at ANMC, our referral center in Anchorage.  The application allows you to take pictures of rashes, ears, eyes, etc., and send them to a provider at ANMC.  Access is given by IT to providers during the onboarding process.
AFCHAN has been used in the past for RMT to view pictures from Health Aides in the villages.  As the Health Aides are now able to upload media directly into PowerChart/FirstNet, AFCHAN is no longer used for this process.
If a provider views photos, or other media such as an EKG from a village, they can bill for it, but must document that pictures were reviewed.
'''See “Learning Live - AFHCAN for RMT - How to Review Cases and Bill for Service'''
==Video Teleconferencing (VTC)==
Video Teleconferencing or VTC enables a provider in Bethel to do a clinic visit with a patient in a remote village.  The VTC system we use is Vidyo.  This is also used by specialists at ANMC in Anchorage to do visits remotely with patients who are here in Bethel. 
VTC/Vidyo is an extremely useful tool as travel is quite expensive and remote visits can save patients the substantial cost and inconvenience of traveling long distances.
The VTC/Vidyo system requires special software, hardware, and training on both the provider and patient ends.  Once these are in place, providers can use the system to see and hear their patients remotely, usually in a village with the assistance of a Health Aide. We have electronic stethoscopes to transmit heart, lung, and abdominal sounds and cameras that can take/save/send pictures and function as otoscopes.
These visits will be scheduled for providers much the same way that regular visits are scheduled, except that the patients in the villages are advised that they will be seeing the provider remotely.  Not all patients are appropriate for VTC visits, but they can be extremely useful for appropriately selected patients who cannot easily travel.
Currently, exam rooms 3 & 4 in Yukon clinic are set up for this purpose, but these visits can be done anywhere with a laptop that has the appropriate software installed.
There are Job Aides available to assist with these visits.


==[[:category:Ancillary Services|Outpatient Ancillary Services at YKHC]]==
==[[:category:Ancillary Services|Outpatient Ancillary Services at YKHC]]==

Revision as of 20:55, 16 February 2019

Overview

The Yukon Kuskokwim Outpatient Clinics provide care for approximately 27,000 Alaska Native Patients, which includes Bethel as well as 48 surrounding villages. The outpatient clinics provide about 45,000 visits a year. Family Medicine, Women’s Health, Obstetrics & Gynecology, Pediatric physicians and advanced professional providers, staff the clinics.

Approximately 50% of the clinic volume is made up of village patients who have arrive in Bethel by plane, boat, snow machine, river taxi, or hovercraft.

Village patients often arrive early or late for scheduled appointments due to plane schedules, weather and other mitigating factors. Many of our village patients are often seen in the village due to the increased cost of travel, weather, work or personal responsibilities at home. Health Aides will initiate care but often times the clinical issue could not be resolved at the local level. When these patients arrive in Bethel, providers attempt to resolve all of their health maintenance issues at that visit so the patient is not traveling back and forth from the village.

Bethel patients make up about 50% of the remaining appointments, which include some of the nearby villages. These patients are seen more frequently on average given their proximity to Bethel.

Our clinic patients are complex with a higher acuity than patients normally seen in lower 48 outpatient clinic settings. Many of these issues are related to household overcrowding, lack of running water, exposure to environmental tobacco smoke and indoor air pollution. All of these factors contribute to increased risk of serious bacterial and viral infections in this population.

Some of the organisms that you will encounter in the clinics are streptococcus pneumoniae, which is the leading cause of pneumonia and neonatal sepsis in the region. Haemophilus influenza type A and B causing meningitis, urinary tract infections, osteomyelitis. Cellulitis, abscess and sepsis infections caused by streptoccous staphyloccous, specifically MRSA. Our most significant and complex medical entity in the region is mycobacterium tuberculosis. Which should always be included in the differential of many of our patients.

Health Aides are the backbone of our unique medical system here in the Yukon Delta. They provide much of the basic care in our villages. Many of the patients seen in clinic have been evaluated by a Health Aide under the guidance of a medical provider through radio medical traffic. These patients are sent to Bethel because they require a high level of medical care. This care may involve complex lab work, radiological images or referral services.

Some of the more serious patients are sent directly to the emergency room with clinic follow up the following day. These patients may not warrant hospitalization at the time, but require close outpatient follow up. These patients are provided a place to stay at the hostel on the hospital campus with daily follow up until the patient is medically stable to return to the village.

The Outpatient Clinic functions more like an urgent care at times given that medical providers are coordinating placement of heplock, IV fluids, urine catheterization, IV antibiotics, incision and drainage of abscesses as well as joint injections and cast placement.

Clinic providers not only provide complex primary care, but also function as specialists given that many of our subspecialists are either in Anchorage or a state away. Providers consult via telemedicine, phone or email in order to develop as well implement plan of care for their patients.

Pediatric patients make up a significant portion of the population. There is a subset of chronic pediatric patients labeled with a RAVEN CPP banner (next to allergy labels). These patients have complex medical issues that require frequent monitoring. The pediatricians, along with pediatric subspecialty consultation, often follow these patients. They have diseases such as congenital adrenal hyperplasia, seizure disorder, pulmonary bronchiectasis, congenital hypothyroidism, septo-optic dysplasia and other syndromes, which are still undergoing evaluation. At times, pediatric appointments are not available and non pediatric providers may see CPP patients in clinic. It is important to consult with a pediatric clinic provider (or pediatric hospitalist provider if no pediatrician in clinic is available) if the patient has any complex issues that need addressing.

Overall we strive to create a medical home for all our patients both near and far. Through the help of departments such as physical therapy, diabetes, tobacco cessation, IMPACT and WIC programs we are able to provide resources to our patients to help them improve and maintain health.

Some clinical recommendations in a nutshell

  • If you are drawing a CBC on a child for illness, always add a blood culture.
  • When doing an Incision and Drainage on an abscess, always obtain a wound culture.
  • Draw a line around the redness of a cellulitis as a way to monitor it.
  • Don’t treat children under 90 days with Antibiotics – w/o having them come to Bethel for a septic workup.

Refer to the YKHC Guidelines and use them when appropriate for all patients. They lay out specific medical plans based on our population's challenging illnesses/and our resistance patterns. If you do not follow YKHC guidelines, then you will be expected to document why you are choosing not to follow them.

Clinic Workflow

Hours

Most providers are expected to work Monday through Friday, 8-9 hour days, ~8am-5pm with an hour for lunch. If nursing staffing allows, and with permission from supervisor, some providers may work 4 x10 hour days. Providers are expected to complete all clinical work by day’s end. Providers are given three ½ days/month for administrative duties, additional if doing village trips.

Scheduling

Providers will have extended appointment times during orientation and when working a full schedule, will have 14 x 30 minute appointments/day with 2 overbooks. 1 hour is designated for 1st Pre-natal visits. Clinics are closed for all Federal Holidays (does not impact PTO).

Nursing

Providers will normally have a 1:1 nurse to assist with visits. Nurses may, contact Access to Collaborative Treatment or ACT (formerly IMPACT), give acetaminophen or ibuprofen for fevers, administer influenza vaccines, and nebulizers independently. They will propose orders, administer medications ordered by providers, assist with procedures, set up rooms, etc. Providers should meet with nurses before and after shifts to review patients, plan for future labs, provide feedback, etc.

Patient Clinic Flow

Patients arrive at YK and first go to registration to check in. This will change their status in the ambulatory schedule in PowerChart, alerting nursing staff of arrival. Nurses will screen patients and either escort the patient back to waiting area, or ‘rooms’ the patient and informs the provider.

Nursing Screening

Nursing staff will check vitals, update social history, assess falls risk, screen for depression and infection, and address immunization needs. Nursing will advise providers if something is abnormal or needs attention.

Case Management

Each village has a case manager in Bethel. The case managers work with different patient groups. If you have a complicated patient who needs several appointments set up, or medical equipment, including e.g., ensure, home health services, etc., you should contact the case manager to assist you in caring for the patient.

Patient Travel

Often challenging due to weather. There may be days when no planes (and therefore patients) arrive in the am, and all arrive in the afternoon. When this happens, Bethel patients may be called to come in if possible. Because folks travel far in many cases and often at substantial inconvenience and expense, providers need to do whatever they are able whenever patients are here in Bethel.

Meetings

Preparing For and Navigating Daily Clinics

First and foremost our clinic does not function like a private practice. Flexibility is key to your success in clinic. The schedule may change many times throughout the day due to travel and Medicaid constraints on patients. In addition, due to limitations in staffing you may have a different nurse day to day. We make every effort to keep the same nurse with the same provider. Below are some reminders to help your transition to outpatient clinics.

Review your schedule with your assigned nurse daily to make sure patients are appropriately scheduled. If you find any errors please alter your charge nurse immediately.

Review RAVEN and VAKTRAK immunization records for each patient. Use the encounter to update any outstanding vaccinations.

Review the problem list, medications, labs and previous documentation in RAVEN prior to seeing the patient.

Occasionally you may need to review the paper chart and RPMS/IHS system. Multiple providers (including health aides) have seen the patient many times prior to them coming to clinic in Bethel . This makes reviewing the chart in RAVEN essential to providing quality and consistent care.

Review and update all patient’s problem and medication lists with every encounter. It is important that any problems (and plans) are clearly documented for any future provider. Meaningful use requires maintaining an updated patient problem and medication lists.

Weather delays: Consider having your nurse call in your Bethel patients to be seen earlier that day for village patients arriving later due to weather. If you have no patients to be seen consider pulling level 4 and 5 patients from the ER. Discuss this with your charge nurse as well as ER charge nurse. This is best arranged by having the provider communicate directly with the emergency department.

Clinic Appointments/Encounters

As a regional medical center, we have limited specialist access in house. Thus, as general outpatient providers, we evaluate and manage many different chronic and acute medical problems that would usually be seen by a specialist. With our extensive network of specialists, we are able to coordinate management for these more specialized issues. Some of these specialties include orthopedics, pediatrics, and women's health.

During appointments in outpatient clinics, providers are expected to complete both sick and well visit encounters. For more specific information about these encounter types, please follow the link in the title above.

Outpatient RAVEN Charting

Paging

Tiger Connect has replaced pagers at YKHC. It should be installed on all work phones and you can install it on your personal phone as well. It is automatically installed on your PowerChart/FirstNet desktop and you should also install this on your regular desktop.

Tiger Connect allows you to text within YKHC and to ANMC. You can text individuals as well as groups. Roles may be assigned as well and as providers go on/off duty, they will transfer the ‘role’ to the subsequent provider.

Texts live for 1 day only and then will disappear, so not intended for permanent documentation

Pharmacy

Our pharmacists are a great resource. Always feel free to ask the pharmacists questions. They are always willing to look up things.

We do have a limited formulary and all formulary items have a green circle, a yellow triangle, or a red square in PowerChart/FirstNet. These symbols cannot be seen within the Dynamic Documentation workflows however, though if medications are selected from PowerPlans or folders, they will be on formulary. The pharmacists will call you if you order something not on the formulary. If you want to order a non-formulary item you can use a Non-Formulary Request form and the pharmacist will determine if the non-formulary item is allowed.

Pharmacy also manages Coumadin patients and does their INRs in the pharmacy. They will give out INR meters to patients, but you need to fill out a pharmacy referral for this to happen. Ask the outpatient pharmacists about it if you have an anti-coagulated patient and they can help you set it up.

Outpatient pharmacists are also available for comprehensive medication review, dosing consultations, pain management, poly-pharmacy review for elders, and prior authorizations.

Ask pharmacy related questions.

  • Available: Mon – Fri
  • 8:30 a.m. – 5:30 p.m.
  • Phone #: 6377 or 6196

Medication Refills

Medication refills are part of your daily clinic responsibilities.

Request for refills will arrive in your Message Center in PowerChart/FirstNet. Our pharmacists have a medication refill protocol that will allow them to refill meds for 6 months if they meet certain criteria, as well as allow them to order labs in your name for your review. Please review the labs and if able, give 6-11 months of refills.

If a controlled medication is ordered, and the provider has access to the EPCS (Electronically Prescribed Controlled Substances), the process will be paper-less. Providers without access to EPCS (locums), will need to print the prescription, sign it, and deliver it to pharmacy.

Currently we are rotating C2 refills through outpatient providers with assistance from pharmacy, checking PDMP. If someone is on vacation, you may be asked to refill medications for patients from their panel. Please review the patients’ labs and refill them as needed. If they are on a chronic pain agreement, please refill them as well. Part of our obligation in doing a pain agreement with a patient, is that when that provider is out, someone will fulfill their agreement and refill their pain medications.

At times when doing RMTs with the villages, you may need to order medication refills. Once you have verified that it is appropriate for them to get the refill, order it in PowerChart/FirstNet by right clicking over the medication.

Radiology

We have a completely digital x-ray system, ultrasound, mammogram, and a CT scanner in Bethel. We do not have an MRI.

Our radiologists in Ohio and read all exams. Our radiologists are available remotely 24 hours a day and once a month, one of them comes to Bethel to do lower GIs, VCUG’s etc.

We can send x-rays to ANMC for additional review by specialist such as orthopedics (see ORTHOPEDICS / TELERAD).

Any concerns regarding orthopedic or surgery x-rays should be sent via Telerad for review.

Procedures

We do many procedures here in Bethel in the outpatient clinics. All providers must be trained and credentialed to do specific procedures. Providers are granted privileges to do procedures during the credentialing process based on their experience and training.

Common Outpatient Procedures Include:

  • Incision and Drainage of Abscess
  • Toe Nail Removal
  • Joint Injections/ Aspirations
  • Skin Biopsy
  • Mole / Skin Tag Removal

In order to add privileges for a procedure after initial credentialing, providers should be proctored by a credentialed provider, observed performing the procedure, and the training documented on a proctoring review sheet. These are then scanned to our credentialing specialist who will let the provider know when they can request an increase in privileges for that procedure.

Time Out should be done and documented for most procedures.

Informed consent should be obtained for most procedures, e.g., IUDs, Nexplanon, LEEP, colposcopy, endometrial, excisional, and punch biopsies. There is a pdf binder file of all consent forms in the YKHC Intranet Document Library, which is accessed only from within YKHC's local network: YKHCintranet.ykhc.org

There are autotexts for many procedures, some listed as ..ed (eg: ..edabscdrsg, ..edabsci&d, ..edadultpe) and others as ..proc (eg: ..prociudkyleena, ..prociudliletta, ..prockneeinjectsynvisc).

Radio Medical Traffic (RMT)

In the villages, patients are taken care of mostly by Health Aides (HAs) who consult with their assigned outpatient providers when patient care falls outside of their standing orders or expertise. These communications are called RMT’s (Radio Medical Traffic).

RMT’s are sent in by Health Aides through PowerChart/FirstNet where they come into message centers under the Proxies Tab as panels (i.e., Chronic Peds, Emergency, Kusko or Yukon). These proxies are set up for providers by IT, usually as part of the initial onboarding process.

At any given time there are assigned providers (some internal at YKHC and some remote providers) for each panel who will review the cases submitted and either discuss the care plan with the Health Aide via telephone, or send back the form with assessment/instructions. They will read the encounter, review orders from the appropriate power plan, modify the orders as needed, submit an addendum to the encounter with their plan, and send it back to the Health Aides.

Emergency cases who need Medevac or immediate attention to Bethel, are called in to the on-call Ward Docs in North Wing and sent to the Emergency Proxy panel.

When Telemed (media files) are reviewed as part of the RMT, providers should add a charge by selecting the order "Telemed Consult Level 1" and insert "..rmtmediareview" autotext (sampled below).

"Appreciate the photos of the _ that were sent to the Bethel provider so that the Health aide could get some help with the diagnosis and treatment plan.
Diagnosis: _
Plan: _
Please give immunizations that are due."

For more details about the process of RMT, urgent RMT, emergency RMT, and different scenarios, please click the title in blue to link to this detailed information.

Behavioral Health

We have a very at risk population for suicide and substance abuse. We have a very high suicide rate. We screen for depression on every visit. If the depression screen is positive during the screening for an outpatient visit in the SRCs, the Wellness Counselor or Behavioral Health clinician in the SRC should be called to see the patient. Click here to see a list of the different resources available in the different parts of the hospital for our patients.

Consults

YK has several on campus (internal) consultants and a network of outside Bethel (external) consultants. Within the hospital, we have a pediatrician in house on call 24/7, high risk OB provider who is either an OB/gyn specialist or family medicine physician with extra OB training on call 24/7, Emergency room physicians available 24/7, Dentist on call 24/7, Optometrist on Call 24/7, TB officers (providers who have received extra training in TB), lactation specialists, HIV, and Wound Care. All other consultants are accessed through a network of providers, hospitals, and services outside YK.

ANMC is our sister Native hospital located in Anchorage, Alaska. They have multiple adult specialists and many pediatric specialists that can be accessed through their system. For any non-beneficiary (or non-native) patients and any specialists not available through ANMC, we contact Providence. Occasionally, we are required to call specialists outside Alaska such as pediatric rheumatology or pediatric neurosurgery. These specialists can be reached at Seattle Children's Hospital or through a second opinion hotline (MEDCON).

For more detailed information, please click the above "Consults" category title to link to a list and description of the provided consulting services.

Specialty Referrals

For patients who need a referral to a specialist, search orders for "Refer to ________" in PowerChart/FirstNet.

"Refer to ___ Internal" means you are referring a patient within the YKHC system. ­*This includes the Specialty Clinics (e.g., Refer to ENT Internal, Refer to Pediatric Neurology Internal, etc.). ­*ANMC (Anchorage Native Medical Center) sends out their specialists out to Bethel on a rotating basis. This allows some of our patients to be seen here for specialty care instead of having to travel to Anchorage. These referrals would be called INTERNAL since the patients are seen here. ­*We will periodically have providers in the Specialty Clinic for Surgery, Orthopedics, ENT, OB/GYN, Neurology, Rheumatology, Hepatology, Infectious Disease, Pediatric Cardiology, Pediatric Pulmonology, Pediatric Endocrinology, and Pediatric Neurology. You can find the current schedule for these providers by signing into AMION with anmc (lower case).

"Refer to ____External" means the patient needs to be seen somewhere other than YKHC (e.g., ANMC, Providence, Anchorage, etc.) For all referrals, the provider documentation should:

  • Always be signed
  • Specify the reason for the referral
  • Include as much past medical information as possible
  • Include Beneficiary/Non-Beneficiary status
    • If non-beneficiary, case management will also need the name of the provider they want to see
    • If beneficiary and they want a non-ANMC second opinion (Medicaid/Medicare), inform the patient that they will be financially responsible for whatever Medicaid does not pay for.
  • Indicate what if any Multimedia files are applicable to case
    • Images and/or scanned documents should be uploaded into Multimedia
    • Dermatology always wants pictures
    • Case management will need to know which Multimedia files should accompany an external referral
  • Indicate STAT status if warranted and inform case management ASAP.
  • Include current patient contact information. If a peds referral, also include escort name/DOB.

Try to be as complete as you can with the referral in giving as much past medical information as possible.

If you are referring to a non-YKHC/non-ANMC provider or practice, please document the name of the provider with the address and phone number. We ask for any outside referrals that the patients make the appointments themselves. Our case managers can assist by sending the referral orders along with all the notes, labs, media, etc.

Please, do not enter multiple referrals for the same patient, same problem. This does not get them done faster; it just bogs down the queue. You can see if a pending referral is being addressed by using the Referrals/Provider Letters and Case Management filters in the Documentation section of PowerChart/FirstNet. You will not see it under orders once it has been accepted by the case management pool.

Case Management does not make ANMC appointments. ANMC will only attempt to contact the patient x3, then send a letter to the patient. A referral would need to be resent if still needed.

Please click here for more detailed information about individual referral types.

Bethel Regional High School Clinic

Village Trips

Telemedicine

We have a web-based application (AFCHAN) that facilitates long distance consultation by allowing our providers to share media with specialists at ANMC, our referral center in Anchorage. The application allows you to take pictures of rashes, ears, eyes, etc., and send them to a provider at ANMC. Access is given by IT to providers during the onboarding process.

AFCHAN has been used in the past for RMT to view pictures from Health Aides in the villages. As the Health Aides are now able to upload media directly into PowerChart/FirstNet, AFCHAN is no longer used for this process.

If a provider views photos, or other media such as an EKG from a village, they can bill for it, but must document that pictures were reviewed.

See “Learning Live - AFHCAN for RMT - How to Review Cases and Bill for Service

Video Teleconferencing (VTC)

Video Teleconferencing or VTC enables a provider in Bethel to do a clinic visit with a patient in a remote village. The VTC system we use is Vidyo. This is also used by specialists at ANMC in Anchorage to do visits remotely with patients who are here in Bethel.

VTC/Vidyo is an extremely useful tool as travel is quite expensive and remote visits can save patients the substantial cost and inconvenience of traveling long distances.

The VTC/Vidyo system requires special software, hardware, and training on both the provider and patient ends. Once these are in place, providers can use the system to see and hear their patients remotely, usually in a village with the assistance of a Health Aide. We have electronic stethoscopes to transmit heart, lung, and abdominal sounds and cameras that can take/save/send pictures and function as otoscopes.

These visits will be scheduled for providers much the same way that regular visits are scheduled, except that the patients in the villages are advised that they will be seeing the provider remotely. Not all patients are appropriate for VTC visits, but they can be extremely useful for appropriately selected patients who cannot easily travel. Currently, exam rooms 3 & 4 in Yukon clinic are set up for this purpose, but these visits can be done anywhere with a laptop that has the appropriate software installed.

There are Job Aides available to assist with these visits.

Outpatient Ancillary Services at YKHC

The Hospital in Bethel provides many ancillary/support services to help provide the best care to the population in this area. Some of these services include, but are not limited to:

Please click on each service above for more details about each or you can click on Support Services to the left and follow that link to "Ancillary Services" to discover information about other Ancillary Services offered.

Outpatient Guidelines

Formulary

Bush Medicine ABCs

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