Ben Collins talks to Verlyn Corbett, General Practitioner and Medical Director 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: So Verlyn, you are a family doctor here at South Central, but you joined the Indian health service back in the 1990s, and you joined South Central, I think about 15 years ago. Tell me about the big changes and what's different about how services are delivered here now.
VC: The Indian health service system was much more of a reactionary medicine system, we spent a lot of time dealing with acute crisis, not doing much preventive work, not much bonding with patients at the time, more focused on the problem of the day, or I always called it putting out fires.
Probably the biggest issue I had with it, was I was not being able to practice any preventive care, and support staff wasn’t there to help, I felt like a bit of an island, where I really had no help.
BC: So, how do things operate now?
VC: In the system I came from, they were always forty people in the waiting room, coming in as a walk-in. So, as fast as you could work, there were people to see, which meant you didn’t get to spend much time, you didn’t dig into some of the underlying issues that drive behaviours.
BC: And in the system now, how many patients do you see per day, how long do you spend with them and how do they communicate with you?
VC: I would say, on average, I have a patient scheduled every 30minutes, sometimes more frequent, but for the most part I've been able to manage my own panel on a 30 minute schedule. Access tends to be very good, most people can get in to see me the same day if they have an issue. We know that booking people out for weeks and weeks and months just becomes problematic.
My scheduler, my CMS, who is my case management support person, frequently takes the first phone call and helps people decide whether they need an appointment or not, or if they need to talk on the phone with the case manager. Or she might even have a question for me, we sit very close to one another and she might even ask me a question about timing of appointments, how much time I might need, when would be an appropriate time, is next week ok, if it's convenient for the customer.
So, that would be one, I do have several customers I communicate with by email, and some, not all, but some have my direct phone number and can call me, and again it depends on the situation, but I think that’s been a real … there's a lot of fear about that, I think, from physicians, customers, or patients, having access to your email that they will just inundate you with questions and problems and things, and try to avoid visits. And actually, I think it's worked out nicely, in that for select people I think it's a good way to communicate, and I don't think anybody has ever been over-run with communications that come that way.
BC: Tell me about how you work in the primary care clinic with your local hospital.
VC: So, we are lucky to have our tertiary care centre across the street from us, so our specialists, our surgeons, our in-patient specialists are right there. Just this morning I had a question for the cardiologist, and I proposed some of my own thoughts, and he agreed with one of them being a good approach to the individual. So, they’re not in the business of generating more work for themselves, so anything I can do to support me as the primary care person is good for everybody.
I keep the customer with me, we work on things together, I get the expert input from the specialist, and I may implement some things, and we have some back-up plans if that doesn’t go quite right, or if there is a next step that the cardiologist might need to do, then we take it to that level. But he immediately answered my page, was very friendly on the telephone, gave me excellent advice and allowed me to institute the plan that I had already discussed with the customer, and got a great opinion without having to make a referral that happened three weeks from now, where I didn’t get to talk to the physician. So, that would be a very typical use of the system.
I can also call the emergency room doctor, if I think somebody is ill enough to need a bigger work-up, or I'm concerned about them, I can call the emergency room doctor and whisk them right there and get them taken care of. Or, maybe I think they need to be admitted to the hospital, I do have the luxury of also talking to the hospitalist who may say absolutely, that sounds like a thing to do. So, I've got almost every resource available, which helps me be confident in not being concerned that I won't have back-up help, but also allows me to work to the fullest extent of my skill set.
BC: Tell me how you measure performance between the different primary care teams, and how do you improve performance across those teams?
VC: So, we look at data, and we look at common ailments like diabetes, heart disease, and we also follow screenings, mammography, colon cancer screening, breast cancer screening, cervical cancer screening, and we set up metrics and we feed that data back to all our staff, including managers, medical directors, none of it is blinded, you can look at anybody’s data, we post it on the wall of the clinic. It becomes a little bit competitive, but not in a sense that we are only going to work on those things that we measure.
But I think that sort of open, none blinded, feedback helps people pick tasks that their team can do better at, and they can learn from other teams who are performing maybe a little better. So we have a concept of best practices, and how does that team get so many of their customers in for colon cancer screening? And they may have a system that they can share with other people, so we are constantly learning from each other.