Category:Outpatient

From Guide to YKHC Medical Practices

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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 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.

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 populations challenging illnesses/and our resistance patterns.

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

8 Hour Shift: 9 a.m. – 6 p.m. approximately
9 a.m. – 12 p.m. > lunch > (RMT) > 1:20 p.m. – 6 p.m.

Non RMT Provider 8 Hour Shift: 9 a.m. – 6 p.m.
9 a.m. – 12 p.m. > lunch > 1 p.m. – 6 p.m.

  • 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.

Radio Medical Traffic (RMT): Mon-Fri. 10 a.m. – 6 p.m.
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.
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.

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

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.

Bethel Regional High School Clinic

Outpatient RAVEN Charting

Clinic Appointments/Encounters

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.

Pediatrics

We have a pediatrician on call every day for the inpatient pediatric patients and for consults. You can also use the pediatricians in the clinics for simple questions.

Children 90 days and under who have a fever 100.4 or higher, or any source of infection, such as otitis media or pneumonia need to be seen by the ED for a septic work up. We do not give antibiotics to children under 90 days without having them evaluated in Bethel. Have the infant sent to Bethel emergency room for evaluation.

There is quite a bit of respiratory illness in the Delta e.g., bronchiolitis and pneumonia. Kids with wheezing/rhinorrhea, stable respiratory assessment and O2 sats (probable bronchiolitis) can be given albuterol nebs in the village and followed closely. We do not routinely give steroids for a first visit of bronchiolitis. If you are giving nebulizers more than Q4 hours in the village, the child must come to Bethel for evaluation.

Kids with a proven UTI need treatment for their UTI once the culture results are back. If the patient is stable they will not get antibiotics until the culture results are back.

See the YKHC Pediatric Clinical Guidelines for greater detail concerning common pediatric problems and recommendations for management at YKHC.

Orthopedics

We see a large amount of orthopedic medicine. X-rays that you are concerned about can be teleraded to the orthopedic surgeon at the Alaska Native Medical Center, our tertiary referral hospital in Anchorage, and they will get back to you usually in 1-2 hours.

If you need an answer from the orthopedist/Ortho Midlevel quickly, you can call ANMC and speak to the orthopedist on call/Ortho Midlevel about 30-45 minutes after you sent the telerad x-ray. You will need to specifically ask for the hand orthopedist or regular non-hand orthopedist when you call ANMC (907-563-2662). There are Telerad referral papers in each SRC. Ask your assistant for one. Fill it out and ask the X-ray tech to Telerad it to ANMC. We do uncomplicated casting and splinting in the SRCs and some reductions using conscious sedation if able. Otherwise the patient will have to be sent in to Bethel for reduction. The outpatient clinic in Bethel, we do casting and splinting. Most reductions are sent to the ER for sedation.

You can always send a patient to Bethel for Walk in Physical Therapy, which is a 20 min appt. from 1- 3 pm each afternoon, if you think they would benefit from a short PT appt. If it is a chronic pain patient or a patient from a village, you should encourage them to make a forty-minute appointment with the physical therapist. Most PT should be done by appointment – so the therapist has 40 min to evaluate the patient.

Ortho referrals can be made to the Bethel Ortho Clinic – by ordering a REFER TO PHYSTICAL THERAPY INTERNAL order. They will evaluate the patient first and then decide how urgent it is. The ANMC Orthopedic surgeons are decreasing their visits – so everything needs to go through PT first. If you have any questions – call PT and discuss the patient with them. visit us about every other month- so referring them first to PT to make sure they have everything they need is a good idea. The orthopedists always like to have xrays that have been done in the last 3 months – before seeing the patient.

We have several hand surgeons who are available in Anchorage and who make Bethel visits about every 3–6 months. Depending on the urgency of the problem you can refer your patients to either place.

Procedures

There are several procedures which can be managed in the outpatient clinics. Below is a list of the most common that you may encounter. We are currently asking for a time-out to be documented and to have an informed consent for most procedures, except for outpatient I and D

Common Procedures Include:

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

Obtain consent for procedure. 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

Select the appropriate power plan in RAVEN.

If you are in the process of updating your credentials, you will need a provider to observe you doing it and complete a proctoring review sheet located in the YKHC Intranet Document Library, which is accessed only from within YKHC's local network: YKHCintranet.ykhc.org. These can be scanned to our credentialing specialist meredith_miller@ykhc.org who can let you know when you can request an increase in privileges for that.

You can use the General Procedure in RAVEN to document almost anything, but they also have pre-completed notes for Trigger points, Nexplanon insertion and removal and IUD insertion.


If you are trying to get signed off and are proctoring on a procedure, you are not able to do it alone. You will need a provider to observe you doing it and write on a proctoring review sheet. These can be scanned to our credentialing specialist Meredith Miller, who can let you know when you can request an increase in privileges for that procedure.

Radio Medical Traffic (RMT)

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.

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

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.

Pre-Operative Exams

We do a large amount of colonoscopies and EGDs. Our current colon cancer screening starts at age 40.

For all pre-op appointments

  • please look at the entire patient chart and do a full physical
  • We have a detailed AMB Pre-op Orders PowerPlan that lays out what labs and EKGs to order for what patients
  • For adult patients, if you are in doubt, order a CBC, CMP, HCG POC, EKG on every patient to make sure all the pre-op screening is done.

Documentation

  • Several public autotext are available and can be found by typing ..surg
  • At the end of the note please indicate the Cleared for Surgery/Not Cleared for Surgery status
  • Make sure to complete the medication reconciliation

Colonoscopy pre-ops

  • once you have cleared the patient, you can order the colonoscopy prep by searching "Suprep"
  • If you have any questions regarding the patient’s condition to have the surgery, please call the Certified Registered Nursing Anesthetists (CRNAs) at 907-545-4014. It is much better for you to confer with them and decide together the day before a procedure whether or not you think the patient is able to do it. There is no reason to make someone go through the prep and then cancel the procedure the next day. That is just mean.
  • Reasons to refer to ANMC

Pediatric Dental Pre-ops

Village Trips

Telemedicine

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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