Clearwater Valley and St. Mary’s Hospitals and Clinics — Orofino, ID


Clearwater Valley and St. Mary’s Hospitals and Clinics work to strengthen the quality of care and address the social determinants of health for low-income people with diabetes who live in sparsely populated and geographically isolated areas.

The program integrates behavioral health workers and CHWs into patient-centered medical home teams to better coordinate care and connect people with diabetes to community resources for social support.

The organization partners with other health care and social service agencies to comprehensively address both medical and social factors relating to health.


Improve quality of care for adults with type 2 diabetes and comorbid hypertension and hyperlipidemia

  • Add behavioral health workers to patient-centered medical home team to address psychological issues for better diabetes management
  • Develop and implement standardized, risk-stratified referrals to a variety of resources in the patient-centered medical home

Decrease diabetes-related health disparities

  • Add regular screens and referrals for social determinants of health to the clinical care model
  • Use community health workers and benefits counselors to connect patients with community resources

Build sustainable partnerships across healthcare delivery organizations and other (non-health sector) agencies that address the medical and social determinants of health

  • Create shared referral processes and progress notes between community partners and healthcare team to build a closed-loop referral system for social determinants of health
  • Multidisciplinary teams better integrate paraprofessionals so that both social and medical determinants of health are addressed.
  • Maintain and expand shared community wellness resources

Identify and disseminate important finding to advance population health efforts focused on vulnerable patients with type 2 diabetes

  • Develop robust evaluation that maximizes use of HIT tools
  • Conduct local evaluation collaboratively with community partners and develop action plans for sustainability
  • Contribute to cross-site evaluation and share findings nationally

Cody Wilkinson, MHA, RDMS

Project Management Coordinator
St. Mary’s and Clearwater Valley Hospitals and Clinics

Cody Wilkinson was named Project Management Coordinator for St. Mary’s and Clearwater Valley Hospitals and Clinics in March 2018. In this role, he supports management teams through project lifecycles and participates in quality and transformational initiatives that drive innovation and growth. He also serves as the manager of the Emergency Medical Services team and as a Diagnostic Medical Sonographer. He holds a Master’s Degree in Healthcare Administration from Colorado State University.

Prior to this role, he completed an 18-month administrative fellowship through Essentia Health. As an administrative fellow, he participated in the development, implementation, and expansion of numerous healthcare programs, including the integration of “best practices” into computerized standard order sets, the implementation of a clinical navigator model into rural health clinics, and the design of the Obstetrics Improvement Initiative Report. Additionally, he co-facilitated the development of the SMH-CVHC Wilderness Medicine Program that engages medical students in the management of medical emergencies in limited-resource areas.

Contact Cody Wilkinson