- 1 Overview
- 2 Clinic Workflow
- 3 Preparing For and Navigating Daily Clinics
- 4 Clinic Appointments/Encounters
- 5 Outpatient RAVEN Charting
- 6 Paging
- 7 Pharmacy
- 8 Medication Refills
- 9 Radiology
- 10 Procedures
- 11 Radio Medical Traffic (RMT)
- 12 Behavioral Health
- 13 Consults
- 14 Specialty Referrals
- 15 Bethel Regional High School Clinic
- 16 Village Trips
- 17 Telemedicine
- 18 Video Teleconferencing (VTC)
- 19 Outpatient Ancillary Services at YKHC
- 20 Outpatient Guidelines
- 21 Formulary
- 22 Bush Medicine ABCs
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.
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.
Providers will have extended appointment times during orientation and when working a full schedule. They will have fourteen 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).
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 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.
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 is challenging due to weather. There may be days when no planes (and therefore no patients) arrive in the am and then all arrive in the afternoon. When this happens, Bethel patients may be called to come in if possible. Because many patients travel far, often at substantial inconvenience and expense, providers need to do whatever they are able whenever patients are here in Bethel.
Our clinics do not function like a normal private practice. Flexibility is key to your success in clinic. The schedule may change many times throughout the day due to travel and Medicaid travel authorization constraints on patients. We make every effort to keep the same nurse with the same provider, but due to limitations in staffing you may have a different nurse day to day.
Below are some reminders to your transition to outpatient clinics:
Review your schedule with your assigned nurse daily (and throughout the day) to make sure patients are appropriately scheduled. If you find any errors please notify 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 the old 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 for these problems) are clearly documented in the problem list for any future provider. Pertinent care plans can be added to the comments section attached to each problem. This provides quick reference for follow up providers. 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.
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.
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 providers. You can text individuals as well as groups. Roles may be assigned as well. As providers in these roles go on/off duty, they will transfer the ‘role’ to the on coming provider.
Texts live for 1 day only and then will disappear, so it is not intended for permanent documentation.
Our pharmacists are a great resource. Always feel free to ask the pharmacists questions. They are always willing to look up things.
We have a limited formulary. All formulary items have a green circle (available), a yellow triangle (non formulary) , or a red square (medication alert) in PowerChart/FirstNet. These symbols cannot be seen within the Dynamic Documentation workflows however, but 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 monitor their INRs in the pharmacy. They can give out INR meters to patients, but you need to fill out a pharmacy referral for this to happen. Ask the outpatient pharmacists about this if you have an anti-coagulated patient. 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 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 pharmacists checking PDMP. If someone is on vacation, you may be asked to refill medications for patients from their panel. Please review the patient's 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.
We have a completely digital x-ray system, ultrasound, mammography, and a CT scanner in Bethel. We do not have an MRI.
Our radiologists in Ohio read all exams. Our radiologists are available remotely 24 hours a day. Occasionally a radiologist 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 section).
Any concerns regarding orthopedic or surgery x-rays should be sent via Telerad for review.
We do many procedures in the Bethel 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 in RAVEN for many procedures. Some are listed as ..ed and include ..edabscdrsg, ..edabsci&d, ..edadultpe. Others autotexts are listed as ..proc and include ..prociudkyleena, ..prociudliletta, ..prockneeinjectsynvisc.
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, click on the Radio Medical Traffic Link at the top of this section.
We have a very "at risk' population for suicide and substance abuse. There is a high rate of suicide in our patient population. 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 the title above to see a more comprehensive list of behavioral health resources available for our patients at YKHC.
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 and TB officers (providers who have received extra training in TB), lactation, HIV and wound care consultants. All other consultants are accessed through a network of providers, hospitals, and services outside YK.
ANMC is our Native referral hospital located in Anchorage, Alaska. They have multiple adult specialists and many pediatric specialists that can be accessed through their system. For 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.
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 some of 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 (they must have Medicaid/Medicare coverage for this), inform the patient that they will be financially responsible for whatever Medicaid does not pay for.
- Indicate what if any Multimedia files are applicable for the referral
- Images and/or scanned documents should be scanned 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. Outside referrals can be made, but patients must 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.
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 send pictures of rashes, ears, eyes, etc., to a provider at ANMC. Access is given by IT to providers during the onboarding process.
The Health Aides are now able to upload media directly into patient's chart: PowerChart/FirstNet for RMT. If a provider views photos, or other media such as an EKG from a village, they can bill for telemedicine consult in our EHR, but must document that pictures were reviewed.
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 primarily 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's clinic 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 in any private room with a laptop that has the appropriate software installed.
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:
- Community Relations/Translation
- Family Infant Toddler (FIT) - provide outpatient physical therapy, occupational therapy, and speech therapy to younger than 3 year old children
- Laboratory Services - full lab in Bethel with some specialty labs requiring send out, limited lab capabilities in Sub-regional Clinics (SRCs), and POC testing in villages
- Pharmacy - in-house outpatient pharmacy support
- Physical Therapy
- Radiology - teleradiology with images reviewed by radiologists in Ohio
- Respiratory Therapy - place Holter monitors, perform PFTs, provide nebulizer machines for home use, and perform cardiac stress tests
- Tobacco Cessation
- Women Infant Children (WIC) - assistance for formula and diet supplements for pregnant women and children up to 5 years old
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.
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