Enhanced Integrated Care

Enhanced Integrated Care

Patients with chronic conditions like diabetes are experiencing better control, fewer complications, and more connected care. That’s not just good for them, but good for the health of our entire community.

 

The “Anatomy” of Enhanced Integrated Care

• Clinical Care Team: Medical providers, dental providers, nurses, medical assistants, dental assistants, behavioral health consultants, registered dietitian nutritionist
• Pharmacy Teams: In-house pharmacists, clinical pharmacy, specialty pharmacy
• Specialized Care: RetinaVue, Maternal Fetal Medicine, dermatology, osteopathy, ophthalmology, asthma
• Specialty Behavioral Health

 

The Power of a Team

Dr. Veronica Hooper, Chief Health Officer, put it simply: “I could hire 100 providers, but without the right team, we’re just running a factory. What’s changed here is that every member of the care team is empowered and trusted to play a meaningful role.”

 

When a patient with diabetes walks into one of our clinics, they’re met not just by a provider, but by a coordinated team: medical assistants trained to perform retinal screenings, clinical pharmacists offering medication counseling, registered dietitians, behavioral health specialists addressing stigma or depression, and outreach teams making sure no one falls through the cracks. It’s a system designed around the patient.

 

With care more efficiently and effectively distributed, patients are getting what they need without always needing to see a physician. That shift creates more capacity in the system: more visits, and more impact.

 

Lives Changed, and Futures Protected

Nothing illustrates this more clearly than our efforts on diabetes. In 2024, we performed more than 2,200 retinal screenings for patients with diabetes. Thanks to this effort, we caught early signs of sight-threatening disease in 28% of those screened. This represents people who might have lost their vision had we not intervened.

 

We have seen measurable improvements in medication adherence and blood sugar control across our highest risk populations. This is not the result of a single initiative, but of a whole system working in concert.

 

The Enhanced Integrated Care model also impacts our employees. Providers and staff want to work where they can make a difference. We have embraced integrated care, and we’ve seen increased interest from medical professionals who recognize that Yakima Valley Farm Workers Clinic has built something special. It’s not just about seeing more patients, it’s about doing better work, more efficiently and with meaningful outcomes.

 

Moving Forward with Purpose

We are driven to optimize what we call “the five rights”: the right care, by the right person, at the right time, in the right place, at the right cost. That’s more than a tagline; it’s our roadmap for system-wide transformation.

 

Enhanced integrated care isn’t a luxury. It’s a necessity to improve the lives of the people we are mission-driven to serve. It’s how we meet the growing demand for primary care despite a national shortage. And most importantly, it’s how we create healthier communities one team, one patient, one transformation at a time.