Southcentral Foundation’s Nuka System of Care
Exporting Alaska’s success in healthcare delivery
An international mix of healthcare professionals attending the Nuka System of Care Conference in June learning about Southcentral Foundation’s wellness model.
© Russ Slaten
Healthcare providers from the nation’s most respectable organizations and from around the world continually make time to visit Alaska to observe and learn the operational and medical practices of Southcentral Foundation.
Southcentral Foundation is a nonprofit organization based in Anchorage under the tribal authority of Cook Inlet Region, Inc., or CIRI, and managed and owned by Alaska Native people. Southcentral Foundation has more than 1,750 employees and sixty-five programs and serves Alaska Native and American Indian people in the Anchorage Service Unit. Primary care services are offered at the Anchorage Native Primary Care Center—part of the Alaska Native Medical Center on the Alaska Native Health Campus—and the Benteh Nuutah Valley Native Primary Care Center, which opened in the Matanuska-Susitna Valley in 2012. Additionally, Southcentral Foundation manages healthcare services at three community health centers: McGrath Regional Health Center, Nilavena Subregional Clinic, and the C’eyiits’ Hwnax Life House Community Health Center in Sutton.
The foundation’s Nuka System of Care, a best practices model for healthcare delivery, has received national and international recognition for its successes in health outcomes, operational efficiencies, and customer and employee satisfaction.
In its fourth year of the Nuka System of Care Conference, healthcare professionals from Scotland, New Zealand, Canada, Singapore, and all over the United States visited Anchorage in June to learn from Southcentral Foundation.
“The old model is disease-focused. Patients come in, and we diagnose the disease and treat it. At Southcentral Foundation the model is thinking about the customer-owner within the context of their home and community, getting to know them in a way that is based on a deep relationship, and then working to promote wellness through prevention, facilitating changes to health behaviors, and diagnosing and treating illness when it occurs,” says Dr. Russell Phillips, Director of the Harvard Center for Primary Care.
Southcentral Foundation saw one of its highest honors for its Nuka System of Care as a 2011 recipient of the Malcolm Baldrige National Quality Award from the US Department of Commerce. Seen as the nation’s highest Presidential honor for organizational performance excellence and innovation, the award brought to light Southcentral Foundation’s ability to increase revenue while cutting costs. According to the Medical Group Management Association, or MGMA, Southcentral Foundation’s per capita expenditures percentage has been lower than the MGMA benchmark since 2005.
About 45 percent of the Alaska Native-owned foundation’s revenue comes from an annual block grant from the Indian Health Service, 45 percent from Medicaid, Medicare, and private insurers, and the remaining from donations and grants. It serves more than sixty-five thousand Alaska Native and American Indian customer-owners on an annual budget of $241.5 million.
“We have what we call customer-owners, and in the traditional hospital setting you’re going to use patient or client, but we changed the word to say customer because in our redesign, our population said, ‘We want to be treated with respect, dignity, and honor.’ And if you show up to a business and try to purchase a product, people are going to treat you really well if they have a product to sell and you’re the customer,” says Katherine Gottlieb, Southcentral Foundation President/CEO.
A strong component of the Nuka System of Care is for customer-owners to empanel with a primary care team consisting of a provider, a nurse, case management support, a behaviorist, nutritionist, and a pharmacist. The team sits in the same workspace to communicate with ease and build meaningful working relationships with one another.
“Teams handle what they can over the phone, and if someone needs to be seen, he or she can be scheduled the same day with a provider or can meet with the case manager, behaviorist, medical assistant, or other members of the team, depending on the nature of the problem. The expectation that everything needs to go through the doctor, who then disburses the work to everyone else, is gone. This allows for processes to be performed in parallel, shifting the work to where it’s most appropriately and cheaply done,” according to the foundation’s document “Transforming Your Practice.”
“The old model’s medical assistant would bring a patient to the back; I might not interact with that medical assistant. I then do what I do in my office, and the patient leaves. And here [at Southcentral Foundation], they actually start every day with a huddle where the medical assistant, the nurse, the provider, and the scheduler are all coming together at the beginning of the day to proactively plan it. So you can come in and be seen quickly and make sure that your needs are being met. And we’re trying to replicate that same thing at [the Harvard Center for Primary Care],” Phillips says.
Hori Awa, CEO of the New Zealand-based tribal organization Waahi Whaanui Trust, says incorporating families in planning and listening to their needs not only brings customer-owners closer to the staff, but builds a stronger bond between employees.
“Taking care of people on the personal approach empowers your staff and helps to retain and enrich staff, and I feel this conference has given me a good sense of how it can be done,” says Awa.
Southcentral Foundation prioritizes the needs and convenience of its customer-owners over the needs of the institution or providers. At both the Anchorage Native Primary Care Center and the Benteh Nuutah Valley Native Primary Care Center, customer-owners can receive same-day access to care because 70 to 80 percent of appointment slots are open at the start of each day. The facility features rooms that fit the appointment with relatively open talking rooms for families to private and quiet rooms to handle more discrete appointments, in addition to exam rooms.
The building setup allows the healthcare teams to more easily take care of their patients. In the Nuka System of Care, one of the chief responsibilities of a provider is to work with customer-owners in establishing a trusting, accountable, and long-term relationship.
“What’s really impressive to me is how aligned everyone is in improving health and how much they invest in building deep and lasting relationships among the staff. They care about each other, which translates into better care for their customer-owners,” Phillips says.
Jess McPherson, Head of Primary Care Development for the Scottish Government in Edinburgh, says Southcentral Foundation staff is the crucial indicator in displaying a positive work and healthcare environment. The way the staff talks about the leadership and how they demonstrate through their actions shows they love working here, McPherson says.
“You get a sense of why these people that work here can do such a terrific job for the patients they’re looking after, because they care,” McPherson says. “They care about their organization, they care about each other, and therefore they care about the patients that they’re serving, and that’s key to why they get it right.”
Nuka System of Care Conference attendees listen to a presentation in June.
© Russ Slaten
Culture of Improvement
Southcentral Foundation measures medical and financial performance through its state of the art database known as “DataMall.” Balanced scorecards, customer reviews, and operational and clinical information is collected and analyzed by the system to provide daily, weekly, and monthly progress reports. Information is readily available to managers, clinicians, and employees to drive improvement and innovation. Well-performing groups are observed and give feedback on ways to improve efficiencies, while lesser-performing groups are analyzed for leadership to provide the team with tools to succeed.
“The idea that even though right now, [the Nuka System of Care] is a leading practice nationally and internationally, no one here is resting on their laurels; they’re continually working to do better. People who live in this area are so fortunate to have a system like this for healthcare. It’s not meant to awe anybody, it’s meant to serve them, and without a comparison it’s hard to realize how terrific it is,” Phillips says.
Gottlieb says the ownership dynamic of the Nuka System of Care comes from the organization’s processes in which customer-owners can affect change.
“If I ask you about your healthcare, and you tell me there’s something you want to improve, and it becomes big enough to where it looks like it could change something for the better or stop harm from happening, then we’re going to change it. And then we’re not only going to change it, we’re going to let you know we did or that it’s under construction. So you said something, we heard you, and we’re changing it,” Gottlieb says.
One of Phillips’s goals in adopting Southcentral Foundation’s practices is to apply integrated care and the overall wellness of the customer-owners for the Harvard Center for Primary Care. Southcentral Foundation integrates behavioral health into primary care. In the Nuka System of Care, behavioral health specialists are readily accessible when customer-owner needs go beyond primary care capabilities. Phillips asserts that research from Southcentral Foundation shows an integrated approach to primary care decreases hospitalizations and the number of days spent in the hospital, resulting in cost savings.
“Given the fact that our country can’t really afford to be spending more on healthcare, there’s an imperative to find ways to reduce costs. This model that’s focused on wellness and prevention has the added benefit of reducing healthcare costs. The research that’s being done here can help support our argument to change the way healthcare is being provided in our hospitals and primary care practices,” Phillips says.
Overall, the Nuka System of Care aims to look beyond the absence of illness and prevention of disease to address the physical, mental, emotional, and spiritual dimensions of whole-person wellness.
“We can no longer blame a hospital system because we’re not healthy. We’re taking over responsibility on how our healthcare is lived out,” Gottlieb says, “So it’s up to us to be well and then walk with our provider to continue that journey of wellness.”
Russ Slaten is the Associate Editor for Alaska Business Monthly.