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Look What Grew Up in Your Own Backyard!

Tuesday, July 18, 2017   (0 Comments)
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Lynn Gerlach, Principal, Tamarack Communication

Back in the early ‘80s, when the Primary Care Associations of the Northwest were first coming to life, and before the explosion of the region’s community health centers, seeds were sown for one of the most innovative and effective health care systems in the Northwest. Established in 1982, Southcentral Foundation (SCF) has transformed the health care of its patient population to an internationally respected and emulated system that Don Berwick called “the leading example of health care redesign in the nation, maybe the world.” 

The history of this health care powerhouse is fascinating, but not nearly as exciting as its future. And the best news is that they will be bringing their informational conference to the Lower 48 states later this year.  

Alaska is the state in question, but for indigenous peoples of North America, that is probably not terribly significant. All Alaska Native and American Indian people were, for many years, subject to the doctrines of discovery and conquest: their lands had been “discovered” and the peoples therefore “conquered,” their fate then decided by the laws of the U.S. Constitution. The one significant difference for Alaska, as opposed to the first 48 states, was that its indigenous peoples were not herded onto reservations, a fact that would prove important in delivery of health care to Alaska Native people 100 years later.

Following decades of indisputably inferior provisions for the health, education, and social welfare of its indigenous peoples, in 1971, the U.S. Congress passed the Alaska Native Claims Settlement Act. It transferred title to 12 Alaska Native regional corporations and more than 200 local village corporations. One of those for-profit corporations (which have been called the most successful businesses in Alaska) was Cook Inlet Region, Inc., or CIRI. 

Southcentral Foundation is Established
Eleven years after it was formally created, CIRI incorporated SCF to improve the health and social conditions of Alaska Native and American Indian people, enhance culture, and empower individuals and families to take charge of their lives. Owned, managed, and directed by Alaska Native and American Indian people, this health care organization began the long journey toward improvement, innovation, and eventually the whole-system transformation that has caught the world’s attention.

Today, the organization employs more than 2,300 people; provides direct care for 65,000 patients (referred to as customer-owners); and has grown step-by-step in size, influence, and effectiveness. In 1984, per Public Law 92-638, SCF began to provide dentistry, optometry, community health, and injury control services and, soon after, substance abuse services. Ten years later it was administering nearly half of the primary care services for Alaska Native people.

Long before that, in 1953, the Anchorage Medical Center of the Alaska Native Service was established to address the tuberculosis epidemic in rural Alaska. By 1999, that hospital, now called the  Alaska Native Medical Center (ANMC), was co-managed by Southcentral Foundation and the Alaska Native Tribal Health Consortium. The services provided by SCF and ANMC are available to the entire Alaska Native and American Indian population of the state—an estimated 108,000 people.

Growth and Transformation
With growth came both the need for and the possibility of transformation—whole-system transformation – with a destination probably unimaginable to those who took the first steps. They did have a vision, though: A Native Community that enjoys physical, mental, emotional and spiritual wellness.

The transformation would include significant philosophical changes and others meant to increase the quality and adaptability of programs, and more importantly, the accountability of providers and customers alike. The first step was to re-imagine the business as an enterprise about human beings, not about tests, diagnoses, pills, and procedures. They viewed the people they serve as individuals who are not just patients but also customers who “own” their own health: customer-owners. Thus, once the tests were performed and the diagnosis was made, the work was not over. They faced the fact that each provider in each separate discipline was actually working with the same patient and that fragmentation of services no longer made sense.

SCF realized that, in most cases, because primary care involved chronic illness, long-term conditions, prevention, and wellness, it is the customer-owner, not the provider, who really has the greatest control over the outcome. Further, this customer-owner does not exist alone, on an island. His or her health is driven in part by relationships; they would be partnering with their care team, family, and others to make a difference over time. 

An Integrated Strategy
These revelations drove the vision, mission, and key operating principles of a new strategy. Every change undertaken henceforth would be part of that single intent, an integrated strategy. Operational decisions about spending time and money, hiring and training staff—every action would be intentionally designed to optimize relationships.

Four fundamental ideas informed the early transformation:
1. The customer drives everything.
2. All customers deserve to have a healthcare team they know and trust.
3. Customers should face no barriers when seeking care.
4. Staff members and supporting infrastructure are vital to success.

With those key ideas in mind, customer-owners were free to define the needs, goals, and values at hand. Customer-owners, SCF realized, take expert recommendations but then make their own decisions. Over time, SCF developed numerous ways to listen to their customer-owners, and they learned to integrate services, functions, and advice into individuals’ lives on their terms in personal partnership, using culturally-competent care. Working with a trusted team of caregivers who are far from strangers, customer-owners decide what they need and when, where, and how they want it. After all, it is the individual’s health journey.

The responsive, integrated care team works together to deliver primary care, but also coordinates secondary and tertiary care with a team that includes a behavioral health specialist, since mind and body are seen as one. All members of the team work at the top of their license, and they see only their portion of the patient population. The integrated care team and customer-owner develop a relationship and everyone is responsible and accountable. Specialists are assigned to particular teams, so they all become familiar with one another and are therefore more effective.

Next, they intentionally removed barriers customers might encounter when seeking care: space, attitude, time, and language. Same-day appointments are available during the week. No longer does the provider manage everything and distribute work to others; work is managed by the part of the team where it can be most appropriately and cost-effectively performed. Telephone and email take care of many issues, with no visit at all. When possible, customer-owners are handed off to specialists immediately, without another appointment. Even the physical facility, inspired, designed, and built by Alaska Native people, promotes dignity, pride, and self-confidence.

Information is transparent across the organization, and regular feedback helps all teams know how they are doing on a range of clinical measures. Demonstrated success and level of responsibility drive providers’ salaries. All new hires complete a week of orientation, with an additional three weeks for front-desk staff. Mentorship programs for new hires have dramatically reduced turnover. Quality improvement is everyone’s job.

And the World Took Notice
Called the Nuka System of Care (Nuka means “strong, giant structures and living things”), SCF’s wholly transformed system quickly earned attention. In 2011, it was the recipient of the Malcolm Baldrige National Quality Award, and SCF began a formal program to share with others what it had learned and built. Using a three-step approach of Discover, Learn, and Transform, the organization has now introduced Nuka to more than 2,000 individuals from 44 states and 24 countries. Prestigious university medical schools like Harvard, Johns Hopkins, Rutgers, and Stanford have sent faculty for training. And, while three-fourths of Nuka System learners are from the United States, other nations, including Canada, Singapore, New Zealand, England, and Australia, consistently send teams to learn SCF’s secrets for success.

SCF offers several types of conferences and webinars, tours and overviews, and even guest presenters for speaking engagements—all to provide a general overview of the Nuka System of Care. Teams and individuals from 18 countries have taken that first step, called Discover. 

Ready for the second step, Learn, participants attend a 3-day Core Concepts conference or bring Nuka training directly to their own site. Others accomplish Learn via experiential learning: a fellowship or residency, for example. Thirty-eight American organizations and 21 Canadian organizations, in addition to groups from seven other nations, have completed that level of training. Their learning is based on the Nuka core concepts of “wellness”:

Work together in relationship to learn and grow 
Encourage understanding 
Listen with an open mind 
Laugh and enjoy humor throughout the day 
Notice the dignity and value of ourselves and others 
Engage others with compassion 
Share our stories and our hearts 
Strive to honor and respect ourselves and others

All Transform organization clients have been American or Canadian to date. Ready for actual whole-system transformation, these organizations learn how to train their own staff with the LETS format: Listen, Explore, Train, Share. Some attend an executive leadership retreat. When they are ready for whole-system transformation, SCF support moves to the client’s own site to enable the process.


The SCF team has grown its training outreach six-fold since it began, mostly reaching top-level leaders (CEO, ED, VP, Director) and direct health care providers, including physicians. To date 73 percent of organizations seeking Nuka training have been health care organizations, and 24 percent of the total have been tribal entities. About a third of the learners come from integrated care delivery systems with the next largest group from academic and research institutions. 

One year ago SCF opened the Nuka Learning and Wellness Center, a facility designed to encourage storytelling and healing, with space for wellness activities and learning circles. The $28 million facility consciously incorporates elements of nature, including natural lighting and Native art. This is now the setting for Anchorage Nuka conferences and trainings. 

In 2017, SCF will offer Nuka trainings in Anchorage, Alaska; Portland, Oregon; and the United Kingdom. They have recently begun welcoming corporate sponsors to help defray the cost of training production and plan to host their first small expo area at their Portland event. 

Those who choose to learn the Nuka system are not likely to be disappointed. “You will discover methods to reduce health care costs and improve health outcomes; learn how to increase customer-owner satisfaction; and find out how to transform your system into one that is customer-driven, relationship-based and focused on whole-person health,” SCF President/CEO Katherine Gottlieb said. “At SCF, our journey is ongoing, and we hope to learn from you as you learn from us.”

[Lynn Gerlach is under contract with Southcentral Foundation as a development consultant.]

 

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