SIMMS/MANN INTRODUCTION 2007-08
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:
*Requires completion of our Women's Progress Note (PINK FORM)
*Prior to ordering a mammogram a breast exam MUST BE done
*Routine screening must not be done less than 12 months apart
*Pts are notified of normal results by mail; we contact them by phone if abnormal.
*Women over 30 with three documented normal annual paps and no history of cervical dysplasia can be screened every 3 years.
c) Family Planning Program (Women under age 55, Men under age 60):
* Requires completion of our Progress Note (PINK FORM)
*Patients should be certified at the Front Desk prior to seeing the provider
*Indicate the method chosen by the patient in your plan
*Women under 25 MUST BE screened for chlamydia annually
*Covers screening and treatment for STD's for male clients if they are given condoms
*Covers Hepatitis B vaccine for men and women (patients not on the Family Planning program are not otherwise eligible for Hep B vaccine)
* Covers HIV screening
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1.Diabetes:
a. 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.
b. 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.
c. 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.
d. Glucose monitors are available only for patients on Insulin.
e. Nutrition counseling: Refer to Health Education
f. QA: We have now 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 and self-management goals. Additionally we track 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. 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 him for referral for biopsy (at MLK). He is happy to confirm any questionable thyroid examinations. For patients with Grave's disease, refer to endocrine clinic at VFC (Centinela Freeman Marina Hospital is providing 6 RAI treatments each year) or, patients can go to Harbor. 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:
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).
6. Other miscellaneous:
* For the Cancer Detection Program, patients diagnosed with moderate to severe cervical dysplasia, cervical cancer or breast cancer are eligible to apply for MediCal regardless of immigration status. All related services are then covered. Have your coordinator refer her to apply for BCCTP.
* Prostate Screening: We have no policy on PSA testing. If a patient requests a PSA, you can do it.
* Dermatology referrals should not be for cosmetic indications.
* Cardiac stress testing is extremely limited, but we can do ETT's in our Cardiology clinic per month. We are working on other cardiac imaging, so this is very limited at this time.
* The Clinic (all 5 sites) has access to only 5 MRI/CT scans per month. We are often backed up, so these should only be ordered in unusual circumstances. They MUST be approved by Karen Lamp or Carol Schwartz, the clinic supervisors. DO NOT ORDER THESE UNLESS YOU CONSULT ONE OF THEM !
* Even though we have fluconazole, treatment of onychomycosis is NOT recommended, unless the nails are painful or the patient is high risk (ie diabetic).
*****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. Your MUST call the social worker for a referral on every patient, at phone number 210-9232.
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 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:
* Look for progress notes which have a preprinted space for the attending note for the MEDICARE and MEDICAL pts. Also, there is a separate form in the vertical file in each charting area for the longer attending notes which are required for interns in the first 6 months and for medical students.
10. Nutrition:
We now have our first registered dietician on staff. Refer for renal and liver disease. For diabetes and cholesterol, start with the health educators FIRST.
11. NEW INTERNS:
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.
Other Resources:
*Walk in oral HIV testing is available Wed. evenings 5:30-7:00 at Venice Family Clinic. VFC is located at 604 Rose Ave, Venice.
*Substance abuse counseling available Friday afternoons at Venice Family Clinic.
*Domestic Violence advocate is available by cell phone 31-678-0714. Please see protocol posted in charting area. Please screen our female patients annually.
*HIV treatment available at VFC.
*Pharmacy run Smoking Cessation clinic (this is the only way patients can get Zyban). Patients must be highly motivated.
*Our coordinators can do a phone follow up on your pt. to see if they are feeling better if you indicate this in your plan. They will not give results of lab tests over the phone.
*We have a "no narcotics or benzodiazepines" policy at the clinic. These can be given in limited amounts on a prescription, using your tamper proof prescriptions, but the patients will have to pay for them.
*We do not do SSI evaluations.
*We have Acupuncture at VFC.
*We have a warfarin testing (Protime) clinic at VFC for chronic pts. on warfarin therapy.
*No more COX-2 inhibitors
*HGH Referrals book: Lists diagnoses by organ system with requirements for testing to be done prior to HGH referrals (i.e. Ophthalmology wants visual acuities, Ortho wants X-rays etc)
*Treatment Guidelines contains detailed protocols on such topics as STD treatment, hypercholesterolemia treatment, etc.
*Emergency Contraception protocol is available
*Obstetrical protocols are available
*Dental referral, when available, needs a special form completed for the referral
*DEXA scans are available, but try and reserve them for patient with multiple risk factors and in whom therapy would be given. A special requisition must be filled out and reviewed by a BHC staff member.
*NEW immunization records for charts, which will appear in a plastic sleeve for new adult patients. For preexisting patients, these cards will be in the charting area. Please hang the form along with the immunization request.
*Residents must write the diagnosis on all lab slips so that labs are justified for insurers. There is a space for this on the top right portion of the form. The lab techs will be returning forms to residents who do not complete them correctly.
Other hints:
*You can prescribe up to 3 months worth of medications if you have a stable patient. Patients should call our appt desk (392-8636) one week before their meds run out for a refill. This is recommended be on patients whose next follow-up appt. is after 3 months.
*If you are NOT sure where to refer a patient for specialty services, check with the clinic coordinators.
*Check out with your coordinator and pharmacist before you leave the clinic to see if they have any questions for you.
*Please inform your coordinator if you'll be absent, or have a planned or call or email Emily Phillimore, ephillimore@mednet.ucla.edu, 310-664-7834.
*If you diagnose pregnancy in a patient, order "Pregnancy Counseling" on a nursing request form. They'll counsel patients of all her options and refer appropriately.
* You can schedule pts. 4 months out.
Thanks!!!!
Deep, Karen and Carol