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Southcentral Foundation's Nuka System of Care

Commonwealth North

April Kyle, MBA, President/CEO

Doug Eby, Vice President of Medical Services

65,000 Voices

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Alaska Native people chose �to assume responsibility

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Alaska Health System

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Vision

A Native Community that enjoys physical,

mental, emotional and spiritual wellness

Mission

Working together with the Native Community to

achieve wellness through health and related services

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Customer-Ownership

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Enhanced Relationship Leads to Increased Health and Wellness

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The Voice of the Customer �as a Valuable Source of Data

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We Asked the Customer-Owner�We Asked the Employees

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We Changed Everything

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Medical Culture Replaced by Relationship, Shared Responsibility, Customer-Ownership, Story, & �Complex Adaptive System

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Hitting The Target: Rock vs. Bird

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Who really makes the decisions?

Acuity

“Control”

The “System”

Customer-Owner/Family

0

Low

High

100%

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Care Team Ratios

Primary Care Team

Integrated Care Clinic Team
2 Behavioral Health Consultants	6 Primary Care Teams
1 Pharmacist
1 Registered Dietitian
1 Certified Nurse Midwife
2 Coverage Physician Assistants/Nurse Practitioners

1,100-1,400 Empaneled Customer-Owners

1

Primary Care Provider

1

Certified Medical Assistant

1

Case Manager Support

1

RN Case Manager

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Integrated Care Teams

Primary Care Provider

Certified Medical Assistant

Community Resource Specialist

Coverage

NP/PA

Integrated Pharmacist

Behavioral Health Consultant

RN Case Manager

Case Management Support

Colorectal Cancer Screener

Certified Nurse Midwife

Dietician

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Providers and Customer-Owners �in Shared Responsibility

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Current Primary Care Projects

Pediatric integration fully
Complex children
New Generations – parenting, parent partners, prenatal
Aging Well Initiative (in place)
Wearable devices
Home visiting
Chronic pain management, addictions
Palliative care, advance directives
Access balance – async/video/text/email/in-person

NOTICE – these minimize office visits & physicians

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Traditional Workflow

Provider

Preventative Med Intervention

Chronic Disease Monitoring

Medication

Refill

New Acute Complaint

Test Results

Case Manager

Mental Health Provider

Referral to Specialist after Assessment

Certified Medical Assistant

Clinical Pharmacist

Dietician

Customer

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Parallel Workflow Redesign

Preventative Med Intervention

Test Results

Medication

Refill

Acute Mental Health Complaint

Chronic Disease Management

Case Manager

Provider

Certified Medical Assistant

Behavioral Health Consultant

Health Care Support Team

Chronic Disease Monitoring

New Acute Complaint

Point of Care Testing

April

SCF leadership created this parallel work flow as a part of the redesign eliminating the provider as the bottleneck with no hierarchy. You can see everyone is key members of the team operating at the top of their license providing efficient and effective care.

Give example – looking at this from the top down starting with the c/o

Medication refill request for metformin
Check last DM/ Labs/ DM eye/foot exam (covering chronic disease management)
Check PAP/ CRC/MAM (preventative care)
if due for MAM then propose orders in same message.

Do all the leg work/ research and Present all of the information in EHR for provider to make a decision to refill medication or not

Then let c/o know they can pick up Rx and let them know they are due for MAM and scheduled annual exam with CBE and same day MAM with one stop shopping.

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Continuum Of Services

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Behavioral Health Everywhere

BHC Primary Care	BHC in Mental Health clinics	Counseling
Talking Circles	Family Wellness Warriors	Traditional Healing
Elders Program, Nutaq	Psych Co-Location	Suboxone Addictions
BURT Inpt Consult Liaison	Crisis Team	Residential – youth, pregnant, adults, etc.
Q-Clubhouse – CMI Child-Adolescent Psych	Wellness Care Plans	4 Directions

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Data & Information Management�Transparency

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SCF Data Mall �Learning from our Approach

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Establish Benchmarks

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Inpatient Discharges

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Emergency Department Visits

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Why listen to our story

Doug

How did we do this?

I am going to speak to the changes the number one reason for these.

The first is generational change of reducing violence. This is community based (Alaska Native). Request for SCF to address. They advocated-allocated funds for it and then volunteered over 10,000 volunteer hours per year to accomplish.

And it is not just generational change in reducing family violence it is generational change in overall health, A provider serves multiple generations of the same family.

The changes in ER visits/Hospital stays was due to redesign of our primary care services. People used to enter through the ER. They now have same day access to their own Integrated Care Teams

We made the HEDIS measures a bench mark for the entire organization to achieve all 2000 employees reach for these same goals.

Employee turnover rate is because they “may” and “own” a piece of the organization- they have the voice to make change- For career development –org. change

We survey customer and staff satisfaction, respond with action.

Baldridge award is 8 years of work

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Savings, Revenues, and Costs

Revenues
Costs
Budget – whole system planning, do what is best
Personnel – do the right thing
Primary care, specifically
Total costs – margin

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Voice of the Customer

Customer Satisfaction Survey

Employee Engagement Survey

Incident/ Accident Reporting

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Questions?

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Háw'aa

Haida

Mahsi'

Gwich’in Athabascan

Igamsiqanaghalek

Siberian Yupik

T’oyaxsm

Tsimshian

Gunalchéesh Tlingit

Quyana

Yup’ik

Tsin'aen

Ahtna Athabascan

Chin’an

Dena’ina Athabascan

Qaĝaasakung

Aleut

Quyanaq

Inupiaq

AwA'ahdah

Eyak

Quyanaa

Alutiiq

Thank You!