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True Patient-Focus: The Nuka System of Care

Thursday, November 12, 2015   (0 Comments)
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Donna Galbreath, Medical Director of Quality Assurance and Matthew Doogan, Technical Writer, Southcentral Foundation


Southcentral Foundation (SCF) began providing health care in the 1980s, contracting with the federal government to provide services. SCF is a non-profit corporation owned by the Alaska Native people in the Cook Inlet region, established in 1982 under the tribal authority of Cook Inlet Region, Inc. (CIRI). At the time, Indian Health Service provided health care for Alaska Native and American Indian people in the Cook Inlet region, and the system was plagued by long wait times and low satisfaction from patients and employees. Although the people running the system were well-intentioned, the care provided was ineffective, did not address the overall wellness of individuals, and was not culturally appropriate. Alaska Native leaders and community members saw the need for change.  


In 1998, Alaska Native and American Indian people took full ownership of their own health care. SCF now provides primary care for approximately 65,000 Alaska Native and American Indian people in the Cook Inlet region. Also, along with the Alaska Native Tribal Health Consortium (ANTHC), SCF co-manages the Alaska Native Medical Center, a hospital which provides inpatient, specialized, and tertiary care. Rather than continue the practices of the past, SCF responded to the needs of the population and implemented major changes in the health care delivery system, establishing the Nuka System of Care.  Described below are key elements of SCF’s whole system transformation that shaped the new system and ensured its success.

“Patient” or “Customer”?

One major element of SCF’s health care system transformation was a shift in the paradigm surrounding the Alaska Native and American Indian people it serves. SCF doesn’t consider the people we serve patients, which sounds passive. Rather, we serve customers and the owners of the health care system; we serve customer-owners. This is not simply a change in nomenclature; it signifies a change in the relationship between the customer-owners and care providers. In a traditional doctor-patient relationship, the doctor diagnoses the patient’s illnesses and prescribes treatment, with the patient’s role in the process often being minimal. The relationship between providers and customer-owners is different. We work in partnership with customer-owners to achieve overall wellness, rather than just dealing with problems as they arise.

SCF recognizes that each individual has more control over his or her own health outcomes than providers, and that when providers build strong relationships with customer-owners, they have the opportunity to have influence with the customer-owner to make healthier choices in their lives. Customer-owners are in control of their own health care and they work in relationship with providers to achieve physical, mental, emotional, and spiritual wellness. Customer-owners choose their providers and develop strong, long-term relationships.

Interprofessional Care Teams

SCF’s focus on relationships is not only concerned with the relationships between providers and customer-owners, but also with the relationships between the providers themselves. SCF makes use of care teams to provide services to customer-owners. Each team consists of a primary care physician, nurse case manager, case management support, and a certified medical assistant. Other providers, such as nutritionists and pharmacists, can be added to the care team as they are needed. Providers work with each other on the same teams, and they share workspace. The primary care provider sits together with the nurse, the certified medical assistant, and the case management support in an open workspace, with other providers co-located. This allows SCF to build strong relationships among providers, which increases their effectiveness when working with each other.

We have also integrated behavioral health providers into primary care. By redesigning the intake process for behavioral health services, we have allowed customer-owners same-day access to a masters-level clinician who can connect them with the right level of services. Often, these clinicians are able to meet the customer-owner’s needs through a brief intervention. If this is not possible, they either coordinate care with a clinical associate or refer the customer-owner to the specific services they need. This process puts the mind and body back together, destigmatizing behavioral needs, and ties back to another central principle of SCF’s system transformation, namely that customer-owners should not face barriers when seeking care.

What are the Outcomes?

The changes SCF has made to its health care system have resulted in improved health outcomes for customer-owners while also allowing us to manage costs. After SCF’s system transformation, SCF saw a decrease in ER visits of 45 percent since January of 2000. Primary care visits for customer-owners have also decreased by 25 percent in the period from 2008 to 2015. SCF has exceeded the 90th percentile in Healthcare Effectiveness Data Information Set (HEDIS) measures in diabetes LDL <100, diabetes care annual testing, asthma appropriate medications, and tobacco screening & quit rates. Ninety-three percent of customer-owners are satisfied with the care provided by SCF, and SCF has also achieved 93 percent employee satisfaction.

With pressures mounting on health care organizations to provide better care while also controlling costs, the story of SCF’s system transformation can provide valuable guidance to health care organizations seeking to move from volume- to value-based care. Being willing to implement major, system-wide change and challenge traditional ideas about health care can lead to improved health outcomes. And focusing on relationships, both between providers and customers, and among providers themselves, can deliver benefits for all concerned.  The Nuka System of Care is all about engaging with customer-owners and working in relationship to support customer-owners in achieving wellness. The SCF experience shows that acknowledging people’s ownership over their own health care, and involving people in their own care, can dramatically improve wellness.


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