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HomePage > Policies and Procedures > Simms-Mann Clinic Practice Guidelines

SIMMS/MANN INTRODUCTION 2008-09

Welcome to the Simms/Mann Wellness Center, formerly known as the Burke Health Center.  We are one of the clinical sites of the Venice Family Clinic, a private, free clinic that serves low income, mostly uninsured patients on the Westside of Los Angeles.  The Clinic is able to provide free services because of generous contributions from various hospitals, laboratories, volunteer physicians, as well as through the use of various public programs and private foundations.  In order to become a patient at the clinic, one must be under 200% of poverty, and live in Los Angeles County.  Patients with private insurance are referred out.  We do accept MediCal and Medicare.

Being a free clinic, you may find that we have a different style and philosophy regarding medical care.  We try very hard to maintain a high standard of care, and do not want to compromise the care that our patients deserve, but must do this in a cost effective manner in an environment of limited resources.

Some of the programs that pay for certain services have strict requirements that we must follow.  For that reason, our staff may present you with additional paperwork, or a different progress note that should be used for that visit.  Here are a few examples:

a) INH program: 
If you have a motivated patient who is PPD + and eligible for INH, refer them to the TB clinic (remember the guideline for LTBI have changed!).  They’ll take it from there; don't worry about getting the CXR or LFT's.

b) Breast and Cervical Cancer Screening:

c) Family Planning Program (Women under age 55, Men under age 60):

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1. Diabetes:

  1. Ophthalmology referrals: The clinic has a "retinal camera" to screen diabetic patients for retinopathy. Patients are placed on a waiting list.  Patients with known retinopathy should be referred to an ophthalmologist. Check the posted "Specialty Clinic" list on the wall to see if ophthalmology is open for referrals.  Otherwise, refer to Harbor General.
  2. Screening for microalbuminuria: If there is no proteinuria (trace or less) on RUA, you can order a urine  Alb/Cr ratio or urine albumin dip stick.  Not necessarily indicated  if pt on ACE or ARB.
  3. Medication availability: Metformin or Sitaglibtin/ Metformin (or Janumet) in now first line if BMI > 25.  For the TZD's, please refer to the posted protocol:  patients must have failed maximum dose of a sulfonylurea and metformin, meet all appropriate medical criteria and have baseline LFTs.  They also must have a social security number, as the meds are available only through indigent drug programs.
  4.  Glucose monitors are available only for patients on Insulin.
  5. Nutrition counseling:  Refer for diabetes classes at Rose Ave
  6. QA:  We have instituted a QA project on all diabetic patients (PECS) to track quality measure on our diabetics.  In particular, we are tracking BP, LDL, A1C, retinal and foot exam, pneumovax, self-management goals, ACE inhibitor, ASA, and statin use.

2. Hepatitis C:
If your patient is Hep C antibody +, check his/her liver panel twice
6 months apart; if LFT's are persistently > 1.5 x normal, you can refer him/her to HGH GI clinic for consideration of treatment. You can also refer them for a consultation to the GI clinic that is held once a month at Simms with UCLA GI Fellows. Remember that hepatocellular carcinoma usually only occurs once the patient is cirrhotic, so there is no indication to screen with AFP's or RUQ ultrasounds, unless they have cirrhosis.  DO NOT DO Hep C quantitative levels.  Remember that depression is a contraindication to IF therapy.

3. H. pylori:
Any patient with documented PUD (by endoscopy or UGI) deserves treatment for H. pylori. However, more commonly we see many patients with non-ulcer dyspepsia. We treat empirically with H2 blockers for 4-6 weeks and see the patient back; if there is not improvement in symptoms, draw H. pylori titer. If there are danger signs such as weight loss, anorexia, or severe dysphagia, or guaiac + stools, refer at first visit for UGI or endoscopy. (See attached Treatment Guideline).  In general, for GI referrals to HGH for EGD, the patient should have already failed a trial of PPI's, and should have had an H. Pylori checked and treated.  We do have referrals limited available for EGD in the community if necessary.
 
4. Thyroid tests:
For uncomplicated hypothyroidism, annual TSH is sufficient. After a change in dosage, recheck TSH in 3 months. Antibody testing rarely alters your treatment plan.  In the case of subclinical hypothyroidism (TSH >5, < 10) consider checking TPO.  If positive, or the patient is symptomatic, consider thyroid replacement.  We have an Endocrinologist, the co-founder of the clinic, Dr. Mayer Davidson, who comes once a month to the VFC, and is happy to consult if you have a challenging case.  He requests that we not refer cases of subclinical hyperthyroidism, (low TSH, normal T3, T4) since there is no treatment.  These pts. should have TFT's checked q 6 mos.  He also sees NO value in thyroid UTZ:  if you have a nodule, refer to Rose Ave with Dr. Beverly Karpman who can biopsy the nodule..  For patients with Grave's disease, refer to Dr Davidson at  Rose who can arrange RAI treatment at Harbor/King.   It is not necessary to do an uptake and scan though the clinic…it will do done at the county for determination of the iodine dose.

5. Colonoscopies/EGD:
DIAGNOSITIC colonoscopy is available on a limited basis at private GI groups in Santa Monica or at Harbor colorectal clinic or Harbor GI.  (The wait time is shorter for colorectal…it is a surgical clinic).  However, there are no resources for screening uninsured patients.  A patient at high risk for colon cancer can be referred to HGH (eg family history).  Our UCLA GI clinic does neither procedure.

6. Other miscellaneous:

*****In general, patients must be referred to HGH for high-end diagnostics.

7. Social Work referrals:
SW referrals for both case management and therapy are available.  A Social Worker is available on call from 10-12 and 2-4 pm by calling the cell phone at phone number 210-9232.  If you want to refer someone after these hours, ask the coordinator to give the patient the walk in hours.  We will no longer be calling patients to arrange appointments.

8. Specialty Clinics:
We now have a number of specialty clinics.  Cardiology is the first and last Wednesday of each month.  Women’s Health is the 3rd Wednesday of each month.  We currently have UCLA volunteer staff at the GI, Neurology, and Dermatology clinics.  Rheumatology is available for SLE and RA only.  The other available specialty clinics are posted in the conference room and change on a monthly basis.

9. Attendings:

10. Nutrition:
We have very limited resource for health education right now, nothing currently available except DM classes at Rose Ave on Thursday mornings.

11. NEW INTERNS / Medical Students:
Make sure you ask the staff to provide you with the SPECIAL ATTENDING FORMS needed for interns in their first six months of practice – FOR MEDICAL AND MEDICARE only.  This form is also needed for medical students to insure adequate documentation.

12. Pain Clinic:
We now have a multi-disciplinary pain clinic that uses physical therapy, osteopathic manipulation, acupuncture, and chiropractic manipulation.  Narcotics are NOT provided.  A specific referral form must be completed for a patient to be considered for this clinic. 

13. Free Spine Surgery:
We now have access to a  Spine surgery evaluation, with Dr. Ramin Rabbani who has agreed to see pts cervical myelopathy, cervical DDD or herniation with radiculopathy, and lumbar spinal stenosis, lumbar disc herniation  with radiculopathy.  Send patients with their XRs.  His clinic will get an MRI with their resources if the patient will be undergoing surgery. Do not send patients who only have back or neck pain, or severe spinal deformities such as kyphosis or scoliosis.  Those cases need to be done in a hospital.  They do not accept Medi-Cal.

Other Resources:

HIV treatment available at VFC.

Other hints:

Website:  Vfc.mednet.ucla.edu


Thanks!!!!

Deep, Karen and Carol

Venice Family Clinic    
Narcotic Prescription Protocol

Because we do not have sufficient case management staff to manage narcotic prescribing
For chronic pain patients, we will limit narcotic pain medications to the following patients:

  1. Terminally ill patients
  2. Acute injury patients, for no more than on month
  3. Serious acute infections, such as dental abscess

Staff providers will write a prescription on the controlled substances prescription pads and have the patient purchase the narcotic pain medication at a outside pharmacy.

Refills will not  be done over the phone as per our usual medication refill process, instead patients will be given an appointment with the staff primary care provider that initially prescribed the narcotics.

For our current patients receiving narcotics for chronic pain, the primary care providers will continue prescribing until patient is able to find another provider to manage there chronic pain.

This protocol will be reviewed with all staff and volunteer providers in order to maintain uniformity.

If there is any concern regarding inappropriate drug seeking, a Patient Activity Report (PAR) for can be downloaded fron the California Medical Board’s web site at:
www.mbc.ca.gov/DOJ_Patient_Profile.htm.

Venice Family Clinic
HIV: Post-Exposure Prophylaxis Protocol for Victims of Sexual Assault

If referred from Santa Monica Rape Treatment Center (they give ARV’s):

  1. See within 72 hours to give full Rx for ARV’s (for 28 days)
  2. Evaluate for side-effects of meds (m. common fatigue, GI, rash, Anemia)
  3. Counsel on importance of adherence to prevent possible resistance and on need for use of safe sex/clean needles to avoid risk of possible secondary transmission
  4. Explain need to come-in for rash, fever, excessive thirst, hematuria, abdominal pain and to call if there is a need for anti-motility agents or anti-emetics
  5. Advise not to start other new meds while on PEP without consulting doctor first
  6. Draw CBC, Chem-7 and LFTs
  7. Schedule follow-up at 2 weeks and 4 weeks (same labs at 2 weeks)
  8. Advise on need of HIV testing at 6 weeks, 3 mos and 6 mos post-exposure

Meds Used for 3-Drug PEP for 28 days:

Combivir and Nelfinavir (may change to Combivir and kaletra):

PEPline 24 hrs
1-888-448-4911

Venice Family Clinic
Outpatient Documentation/Management of Hyperglycemia in Type 2 Diabetes Mellitus

In an attempt to standardize care and documentation, please include the following in your progress note when the glucometer reading is over 400 mg/dL or “high” at a clinic visit for Type 2 diabetic patients.

  1. Document symptoms of hyperglycemia. Pertinent positives and negatives to include, for example, are (+/-) dizziness, chest pain, fatigue, weight loss, SOB, nausea, vomiting, dysuria, fever
  1. Medication history: document when patient last used insulin or oral agents
  1. Obtain random UA dip in clinic document presence of ketones. If in house UA dip reveals moderate to large ketones consider referring to emergency room. 
  1. Physical Exam document
    1. assessment of mental status
    2. hydration status
    3. orthostatics if patient is symptomatic
    4. signs of infection
  2. Document result of EKG if the patient is complaining of chest pain
  1. Treatment options if hospitalization is not required may include the following:
    1. provide appropriate medications (for newly diagnosed diabetics under the age of 65 start on maximum OSA; for known diabetics, restart meds)
    2. If pt. requires insulin for the first time
      1. Give NPH insulin that night and the following morning
        1. Obese: 20 U NPH AM + 10 U NPH PM
        2. Lean: 10 U NPH AM + 6 U NPH PM
  1. If patient refuses referral to ER, have them sign AMA form and give close follow up. Give warning signs/precautions for patient to seek care in ER

 

Recognizing that every case is unique, Dr. Mayer Davidson is available by beeper for consultation on any cases at 323-848-0175.

Venice Family Clinic
Simms Algorithm for the Management of Hepatitis C Patient

  1. Whom to Screen:
    1. History of IV Drug Use
    2. Recipients of Blood transfusions prior to 1992
    3. Chronic hemodialysis patients
    4. Persistent increase in ALT, AST
    5. Following needle stick or mucosal exposure to Hepatitis C
    6. Children born to mothers with Hepatitis C
    7. High risk sexual behavior or sexual partners of patients with Hepatitis C
    8. Patients who share instruments for intranasal cocaine use
  2. What to order?
    Hepatitis C by ELISA only
    Do not order Recombinant Immunoblot Assay (RIBA): $140.00
    Do not order Polymerase Chain Reaction (PCR) testing quantitative test: $200.00
  3. What to do if the patient is Hepatitis C positive?
    1. Recommend lifestyle modification – particularly Alcohol cessation.
    2. Avoid hepatotoxic medication
    3. Prenatal (~5 % risk) and sexual counseling (~ 5% risk).
    4. Sharing razors and toothbrushes should be avoided. Covering open wounds is recommended.
    5. Injection needles should be carefully disposed of using universal precaution techniques. It is not necessary to avoid close contact with family members or to avoid sharing meals or utensils.
    6. Hepatitis A and B vaccination if possible but, we do not have Hepatitis A or B vaccines at Simms or Venice
    7. Testing: ONLY
      1. Routine LFT’s
      2.   Hepatitis B surface Antigen (HepB cAg), Hepatitis B surface antibody (HepB sAb) and Hepatitis B core antibody (HepB cAb)
      3. DO NOT order routine Ultrasounds, or Alpha Fetal Proteins (AFP) unless there evidence of cirrhosis, or Hepatitis C viral RNA. 
  4. Whom should we refer to Harbor General Hospital GI:

Patients with increased LFT’s patients with elevated LFTs (>1.5x normal) over a 6 mos period, (we must send documentation of this) and in whom there is no contraindication to interferon and the patient is interested AND will be compliant with treatment.  If they have been alcoholic, they must have been sober for at least one year.

Contraindications include:

  1. Severe depression
  2. Ongoing substance abuse
  3. Hepatic decompensation  (albumin <3.0 g/l, bilirubin >51.3 µ mol/l (30 mg/l), PTT >3.0 s)
  4. Portal hypertension
  5. Hypersplenism  (leukopenia (<2 x 109/l), thrombocytopenia (<7 x 107/l)
  6. Autoimmune disease   (polyarteritis nodosa, rheumatoid arthritis)
  7. Major system impairment  (cardiac failure, COPD, uncontrolled diabetes)
  8. Pregnancy