St. Mary's Health and Clearwater Valley Health— Orofino, ID


St. Mary’s Health and Clearwater Valley Health (SMHCVH) 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 findings 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
Idaho Biking

St. Mary’s Health and Clearwater Valley Health (SMHCVH) is focused on supporting unmet medical and social needs:

  • SMHCVH established a community health worker (CHW) program to increase the outreach of their diabetes education and support overall population health efforts. CHWs are hired from the communities they support and seek to build interpersonal and institutional trust with patients and community members.
  • SMHCVH Population Health staff established a partnership with the Idaho Food Bank (IFB) as part of their Hunger To Health initiative. As part of the initiative, clients can visit a mobile IFB location for food resources where co-located SMHCVH CHWs provide access to educational materials, medical screenings, and referrals to other medical services and programs. Both organizations hope to expand their reach to individuals that avoid traditional medical care and establish a comfortable and convenient resource outside of the traditional healthcare setting.
Idaho-Cody Wilkinson

Cody Wilkinson, MHA, RDMS

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

Cody Wilkinson serves as the Director of Population Health for St. Mary’s Health and Clearwater Valley Health in northcentral Idaho.  He also serves as a grants/projects manager and as a diagnostic medical sonographer.  With a special interest in healthcare transformation and population health, he participates in his organization’s Leadership Council and serves on their Bridging the Gap: Reducing Disparities in Diabetes Care Steering Committee.

Inspired by a love for the medical sciences and a joy for serving others, Cody pursued a Bachelors of Sciences Degree in Radiographic Sciences from Boise State University.  He later enrolled at Colorado State University, where he earned a Master’s Degree in Healthcare Administration.  He has additional training in Lean Principles and Value-Based Care and is a recent graduate from the National Rural Health Association Fellows Program.  He has held numerous staff and administrative positions in the medical field, including an adjunct faculty position at Lewis-Clark State College. 

A native Idahoan, Cody spends his leisure time with his family in the great outdoors where they enjoy backpacking, foraging, and hours around a campfire.  His favorite pastime is picnicking with his family on an unnamed beach or ridge in Idaho.

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