Outpatient Clinic Introduction
The Yukon Kuskokwim Health Corporation is responsible for the care of patients in Bethel, population around 6,000, as well as patients from 58 villages. The YK Delta is about the size of Oregon, and patients travel great distances by plane, boat, snow machine, river taxi, or hovercraft for health care. The outpatient clinics see about 45,000 visits a year and care for approximately 25,000 people.
It can be challenging to see patients quickly when the patient has an airline check-in they want to meet. It is wise after walking into an exam room to ask the patient if they have a check-in time soon. This way you will know how much time you have for the visit. It is not uncommon that there may be blizzard conditions, ice, or fog on the ground that prevent the coastal and far away villagers/patients from keeping their appointments. When that happens, patients from nearby villages and Bethel may be available to be seen.
Our patients are of a higher acuity and tend to be sicker than patients you would see in a traditional lower 48 family medicine clinic. We have 10 times the rate of strep pneumococcus and 50 times the rate of RSV bronchiolitis, which leads to more septic workups in neonates and increased amounts of pneumonia for the entire Delta.
It is not unusual to feel like you are functioning like a specialist. You may need to contact several sub-specialists during the day for advice. Always feel free to talk to other Bethel providers to discuss a complicated patient. Remember that the Health Aides in the villages have already prescreened 50% of the patients we see and only the sicker ones have been referred to Bethel, so we tend to be more aggressive with our sick patients.
Some clinical recommendations in a nut shell are:
- If you are drawing a CBC on a child for illness, always add a blood culture.
- When doing I & D 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.
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.
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 certain criteria are met, and they can order labs in your name for your review. Please review the labs, and if able, give 6-11 months of refills.
You may receive medication refill request from pharmacy for patients that you have not seen when the initial ordering provider is not in clinic. Please, review the chart and medication for refill. If it is a reasonable refill request, please sign off on them with the goal to decrease delays in getting medication to patients.
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 controlled substance refills through outpatient providers on a weekly basis. Please see CHRONIC PAIN section for further information.
At times when doing RMT, 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 by right clicking over the medication.