- 1 Overview
- 2 Preparing For and Navigating Daily Clinics
- 3 Outpatient RAVEN Charting
- 4 Clinic Appointments/Encounters
- 5 Orthopedics
- 6 Procedures
- 7 Consults
- 8 Clinic Case Management
- 9 Specialty Referrals
- 10 Village Trips
- 11 Telemedicine
- 12 Outpatient Ancillary Services at YKHC
- 13 Outpatient Guidelines
- 14 Formulary
- 15 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 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.
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.
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.
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.
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.
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 firstname.lastname@example.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.
For IM consults you will need to call ANMC and ask to speak to the consult IM physician. If admitting – then go to the Admitting IM physician at ANMC.
There is a pediatrician in each hallway. For a simple peds consult, you can talk to the person in your hallway. If it is a complicated one, or a possible admission, please page the peds on call providers – through the operator or text paging system.
For breastfeeding questions we have 1 lactation consultants, Dr. Roll in clinic or WIC as has Peer Lactation Educator.
Any ER emergencies, if in Bethel, simply call the ER and talk to the MD on call to transfer and have your charge nurse talk to their charge nurse. In the subregional clinics feel free to call the ER MD with questions, or if you are thinking about medevacing someone, call/page the wards doctor. You can use AFCHAN system to telemed things to them to have them review images as well. You can also do that with any of the FP docs who are in the clinics and especially if they take care of the SRC that you are in.
We have a large amount of TB here. For questions on diagnosis and treatment, contact one of our physicians who has special training in it—Dr. Ron Bowerman, Inpatient, or Dr. Roll, Kusko and Dr. Chyi and Dr. Mondesir, Peds. The easiest way is to page them.
If none of these local providers are available you can contact Dr. Michael Cooper, MD, MS Section of Epidemiology Tel: 907-269-8000 Fax: 907-563-7868 Email: email@example.com
Dr. Hunt and Dr. Roll are our local HIV experts. Contact them with any questions about HIV. If these providers are not available you can contact Alaska State Epidemiology Section on HIV, Tel: 907-269-8000 Fax: 907-563-0453
Physical Therapy is our only Wound Care at this time. Basic abscesses, etc., can be sent to nurse-only clinic in Specialty Clinic for repacking, but with any concerning wounds you need to involve physical therapy. Call PT as they are not checking telemed at this time.
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
For patients who need a referral to a specialist, you can order a Refer to ________ in RAVEN. We have divided the Referrals into Internal – meaning the patient is seen here in Bethel – examples Refer to Internal ENT, Refer to Internal Pediatric Cardiology.
For referrals that are not on YKHC property you select Refer to Adult Surgery External, meaning either ANMC or another surgeon that you need to specify. If you are referring someone outside the ANMC system please document the name of the provider along with the address and phone number. We ask that for any outside referrals that the patients make the appointments themselves, but our case manager will send the referral along with all the notes and labs, etc., so the referral providers have all the information.
ANMC (Anchorage Native Medical Center) sends their specialists out to Bethel on a rotating basis, so some of the patients can be seen here which decreases their need to travel into Anchorage. These referrals would be called INTERNAL since the patients are seen here. The specialties that come out here are primarily Surgery, Orthopedics, ENT, OB/GYN, Neurology, Rheumatology, Hepatology, Infectious Disease as well as Pediatric Cardiology, Pediatric Endocrinology, Pediatric Pulmonology and Pediatric Neurology.
Try to be as complete as you can with the referral in giving as much past medical information as possible. Anything needing to be seen by surgery will need an accepting physician. So you will have to contact the surgeon on call at ANMC (1-907-663-2662) and ask for the on call surgeon. Explain the situation between you and the surgeon to decide whether the patient is best suited to be seen in Bethel or Anchorage. Make sure if you consult with an ANMC provider, you write their name down on the referral.
Please document all hospital service referrals the same way- Examples – Refer to FIT, Refer to Physical Therapy. Refer to IMPACT, Refer to Behavioral Health, Refer to Nicotine Cessation etc. Please include good contact #’s and that the patient agrees to talk to BH.
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