Ben Collins talks to Doug Eby, Vice President of Medical Services at Southcentral Foundation, about the 'Nuka' system of care they use in Alaska.
This video was filmed while Ben was in Alaska as part of his research for a report.
BC: Now your mission statement focuses on the concept of wellness rather than treating diseases.
BC: What does that mean in relation to how you do our work?
DE: Quite a while ago, we said that this business of disease-specific approaches really didn’t work very well for vast majority of the people – especially those who cost us the most and visit us the most often. Many people have multiple conditions, there are multiple pathways, given multiple medications and are not sure how to put that altogether. We instead meet a person where they are – the whole person – mind and body back together and then craft a plan with them that they’re willing to do, incorporating disease-specific knowledge into the more comprehensive whole person plan. It’s much more likely they’ll do what they say they’re going to do and actually get to better outcomes with that approach than just a linear, you know, “Here’s your Diabetes plan. Here’s your Asthma plan. Here’s your HIV plan – hope you do all of them perfectly.”
BC: Why are relationships so important?
DE: Right. This is the core of our entire system is that understanding that at the end of the day, it’s what the person does in their life living day to day that determines whether they get chronic conditions and how well they live with them or that they decompensate to the point of needing medical care. So the person in control for most medical expenditures and outcomes these days is the person on the receiving side – the patient, or as we refer to them, the customer owner. If that’s true, then the main thing we can do is to try to influence what they do and the only way you do that is through influential, long-term, trusting, personal relationships. So our medical practice is primarily about influential relationships, getting people to choose different things to be healthier over time. It also happens to be our management philosophy because if you can get your staff internally motivated with passion around something they believe in, they’re also going to go the extra mile. So our management philosophy, our clinical philosophy – same thing.
BC: What’s truly innovative about your model?
DE: I think the part what makes us really different is the part you can see easily first which is the actual structure of the delivery system. So we have these primary care teams that are in close proximity where they sit and understand that relationship is our main business, but backed up then by integrated care team so that people coming to us have access on the same day to the primary care provider, case manager, behaviourists, dietician, pharmacist and midwife – and that’s all in the same place integrated for them to access any day they want for any reason they want. So that’s the structural piece, but there’s other layers behind that. We have spent a long time becoming very sophisticated around all the dimensions it takes to create a capable delivery system at scale, sustainable logically over time and that means a whole lot more emphasis on workforce development, improvement capability, leadership, alignment of activities and philosophy and corporate structure and philosophy over time, corporate culture with an extreme adherence and focus on results and outcomes. So that’s kind of the second piece, and the third piece is developing a true learning organisation when every one of our 2,000 employees understands passionately what we’re about, can speak to it, can act on it and help mobilise in the direction that we’re going.
BC: So what has been the impact on outcomes for your population?
DE: Right. We’ve seen huge difference. So our per capita visits to the emergency room are down by over 60%. Our admissions in hospital days are down by over 60%. Our visits to specialists and sub-specialised care are down by over 60%. Our health outcomes are dramatically improved. So our Diabetes outcomes, Asthma, HIV put us in the top 25th percentile for the nation – we used to be in the bottom 5th percentile because we have a very at risk complicated population, and our staff turnover is one fifth of where it used to be. So happier people, better clinical outcomes, dramatically reduced utilisation of high cost areas – so lower total costs.
BC: And what has been the impact on costs?
DE: It’s about half per person per year of what it used to be, because so much less emergency room and hospital. If you get to the per member per month and per member per year cost amount, we’re more comparable to the European spend. So in between $3,500 and $4,500 a year per person per year which is about half of the national average in the US – especially for a more complicated population.
BC: What advice can you give us for creating similar models in our local health systems?
DE: Moving to local controlled and local ownership was a pivotal change for us. Understanding that the control at the individual level lies with the individual in the context of their family was very pivotal. So if I were to give the NHS advice, I would suggest put the pots of money together, give control locally, allow them to propose back structures and processes they’d like to use, listen deeply to the customer voice in the community and then try and structure that into something that’s responsive in a way that people will want to own and drive their own health journey instead of having it being done to them or being done for them.