Provider Based Clinic
We have been working towards the goal of being a provider-based clinic. This will allow us to become 340B eligible. The 340B Program is a federal program that requires pharmaceutical manufacturers participating in Medicaid to sell outpatient drugs at discounted prices to health care organizations that care for many uninsured and low-income patients12. Eligible healthcare clinics and hospitals can purchase outpatient drugs at a 20-50% discount through this program3. The program involves a mandatory transfer of resources from one group of private entities (manufacturers/wholesalers) to another (providers)3.
Family Medicine Clinic
The family care clinic was originally a separate building next to the hospital. But it is now part of the hospital as we built a reception room to connect the hospital and clinic. The reception area and clinic have a lot of local art and photography from our patients in the community.
We have a team-based care approach and have a total of 18 exam rooms and two procedure rooms. Each provider has two medical assistants and two exam rooms. One MA will room your first patient, then will get you when the patient is ready to be seen. We use the DAX AI (phone listening application) that does the note writing. The MA puts in the orders, and each physician approves the notes/orders after the patient encounter. Then you will go onto the next room where the other MA has the patient ready. The MA will get the next patient appointment scheduled and print the aftercare summary and walk the patient out, and bring the next patient back. We have two nurses that handle the triage calls during the day.
In our procedure rooms we do circumcisions, IUD, colposcopies, joint injections, laceration repair and skin biopsies. A physician that wants to do colonoscopies and EGDs can do so. Expected volume can be 3-6 per week in the hospital’s procedure rooms. A physician interested in sports medicine or ultrasound guided therapies could develop those service lines. We see newborns through geriatrics and Dr. Lewis and Dr. Neill also help cover hospice shifts on occasion.
We have a visiting cardiologist, and their Echo technician come every Tuesday from in the Heart and Lung Center in Bend. The general surgeon visits twice a week performing mostly ambulatory cases. In the past we had a full-time general surgeon and hope to ramp that back up. We have 2 OR’s and 1 procedure room. We also have an outpatient podiatrist. We have a community provider, Dr. Plant, doing scopes one half day a week. We are considering bringing in a GI once or twice a month too. We have a psychologist and a clinical pharmacist. There is also a respite room for physicians to relax within the clinic. The basement is set up as a workout room with two showers for physicians and staff.
Obstetrics/C-Section Option
There is also an opportunity for a physician to do Obstetrics and/or C-Sections. We average 25 deliveries a year per doctor and average close to 150 deliveries annually. We have four providers doing Obstetrics, and four doing C-Sections (Dr. Aimee Neill, Dr. Bill Irvine, Dr. Katie Synder, Dr. Gary Plant). One of our providers (Dr.Savage) is getting close to the end of their career and will consider giving up their C-Sections. To be recredentialled in C-Sections, you need to do 12 within two years. To get credentialled to do C-sections, you need at least 24. For our OB/C-Section credentials you should expect to be proctored during your first 10 vaginal deliveries and your first five C-Sections. We don’t have midwives in town.
Our C-Section rate is less than 20% due to a patient population that likes a more natural birth approach. All C-Sections are performed with two doctors. That way if the baby needs resuscitation, one of the providers can take over that responsibility. We have two full resuscitation teams, which include respiratory therapy. Our epidural rate is about 50% given our patient population. We do not do VBACs and will refer them to providers in Bend at about 36 weeks. We will also transfer patients with a BMI over 50, gestational diabetics on insulin, if they are under 36 weeks or have a known fetal anomaly where they are going to need the NICU. If a patient presents in the ED, the nurse will perform a labor rule out, give us a call, and send the patient home. We have set up automatic protocols for any patient that presents. Since we all live within 20 minutes, many times the physician can be at home while the patient is in labor, until it gets closer to push. We have a good mix of tenured and junior nurses.
The physicians have a close working relationship and cover for each other if one of them can’t make it to the delivery. We don’t have a NICU and deliver at 36 weeks and rarely twins. MFM consultations are done by a physician that comes to Bend once a month. We can also call him with any questions. The Woman’s Clinic OBGYN’s are also available for consultations.
Our OB call schedule is 1:7 and will go to 1:8 when a new provider joins the team. There is a 20-minute response time so these providers must live within the community. CRNAs are available 24/7 for OB epidurals and C-sections.
Hospitalist Option
Our physicians also cover the hospitalist service. Each week one physician covers Monday-Thursday, 7a-7p and the others will rotate through the nights (7p-7a) on Monday, Tuesday, Wednesday and Thursday. There is a care conference at 10am where all the nurses and case management meet and go through all the patients. The weekend coverage for Friday, Saturday and Sunday has one doctor covering the day, and one doctor covering the evenings and overnight. The shifts are spread out fairly amongst the entire team. One of the C-Section providers will also be matched up 24/7
We have 18 beds in the unit. The average daily census is about 12-14 including the skilled nursing patients, which represent about 30-40% of our patients. We are required to see skilled nursing patients once a week. Our hospitalist will do any admissions during the day. The day shift stops taking new patients at 6:30p and have the new provider at 7p take them. If a patient presents in the ED after midnight, and it’s a stable patient, the ED will put in holding orders and the hospitalist will see them in the morning. When we have seen all our patients, we can go home. On most days, the doctor is home about 5p.
Codes are run by the EM doctor and intubations are performed by the EM doctor with a respiratory therapist. We also have a rapid response team. We do IMCU care not ICU. We don’t do vents but have patients on drips. We have a Psychiatric Assessment Team (PAT) that does the initial assessment or have an emergency mental health issue. Any procedures like central lines, chest tubes are typically done by the EM doctor. Once stable, those patients are sent to another hospital. A hospital can do procedures if they want to, but it is not a requirement. All family medicine doctors are ACLS trained.