Appendix C: Model of Care
Model of Care
BRISTOL BAY AREA Health Corporation
Chronic/ Episodic
Acute
Maternal health, antepartum/ postpartum Heart disease, HTN, Pacemaker, AFib, PT/INR Respiratory, Chronic care: Asthma, COPD, TB Psychiatry RPA and Behavioral Health/Therapy Palliative care/end of life care
Emergency/injury/trauma Onset of Respiratory, digestive, skin, ear, musculoskeletal, urinary, suicidal ideation, alcohol or drug withdrawal, eyes, reproductive health, problems
Coordinated Care Plans Substance use treatment
Diabetes, Hep B/C
HIV Treatment Pain management Pain management
Affordable transportation Law Enforcement/Safety Officers in each village Emergency notifications
Well Child visits
Family planning & Sex education Immunizations Adult & Child Screening: STI/HIV/Hep C, Syphilis, Hep B/C, TB Nutrition, Education, Exercise, Obesity prevention Access to substance use treatment/harm reduction Education in accident prevention, safety of guns, ATV, helmets, boating
Access to home health/ personal care attendants Accessible Care: Clinics within villages VTC/Zoom/AFCAN Safe clean housing for all community members (heat, clean water, septic) Affordable food/access to produce /harvest subsistence foods
Social Determinants of Health
Public Health Promotion
PATIENTS
Reliable telecommunications
Counseling and BH services Support for clean sober living
Rabies awareness
Public schools
Home visits Annual lab work Glucose Monitoring Elder care/palliative care Optometry, WIC, Infant Learning, Audiology,
Cancer prevention and screening: Colonoscopy, endoscopy, mammogram, annual pap, lung CTs Annual Medical Exams: BP, labs, DEXA screening Diabetes prevention Controlled HTN
Physical Therapy, Behavioral Health Dental consult, oral health screening Access to medications Patient medication management
Health Maintenance: Village Clinic Outreach
Population Health
Strategic Cancer Plan | 33
We provide quality health care with competence, compassion, and sensitivity.
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