Intentional whole health system redesign: Southcentral Foundation's 'Nuka' system of care

BC: Katherine, Southcentral has developed what you call the Nuka model of care. What does Nuka mean and why is this concept so important?

KG: Well we received the title because Nuka’s being used across Alaska for giant living and breathing things like mountains and rivers and it’s a name that’s tossed around in the Alaska community for things that are loved. People always ask us what can they do? What is possible to duplicate in a healthcare system across a nation or a global world and what’s similar to us that could be duplicated? The way we built our buildings – part of our infrastructure – was to look at our community, see what was of value to them and then build the infrastructure – the buildings. So first and foremost, it would reflect our culture and as you see our buildings – if you walk around them – you’ll see our native culture in place, native arts and crafts, the colours are tied to the environment, there’s a feeling and sense of openness, very transparent, the walls are down, lots of window space and materials that are built from our environment. And the sense about that was as our community would come in to receive the services, they would feel a sense of ownership. So the beginning of a healthcare journey for our population and what we thought was help our community to own their healthcare system and if they’re going to own their own their healthcare system, they should feel it when they first walk in the door. But not only that, they should feel a sense of healing and of a sense of ownership and a sense of honour.

The buildings that were in place prior to our assumption didn’t have that sense and feeling. They’re structured around government ownership. So the colours were green and yellow, and the facilities were not… The priority was not on the facilities. So we walked in the door, it had not a good smell. The walls were cracked. Floors were cracked, and you felt like you were entering some kind of sanatorium instead of a place of healing. So one of the best comments we had back on a survey from our customer owners after we built our buildings was that they began their healing journey from the moment they stepped into a building. We were inheriting employees overnight that had worked in a government system. If you’re going to move towards an organisational structure and change of an entire employee community, somehow, someway you have to get them to look at there’s a big change happening and not bring them through that change where they’re fatigued or they get discouraged or they don't feel a buy-in into the process. And so right at the very beginning, we had our employees who transferred from a government system into our system knowing already there was change and the change and feeling and sense is that you get to have say – if you work for our organisation – in even the structure and the place you’re working, the environment that you’re in.

So we’re sitting in the traditional healing section of our primary care system and this was designed by our traditional healers. So they had input into how it felt and what it looked like.

BC: Now one very striking feature of Southcentral for an English observer is the facilities. Another really striking feature is the investments that you’ve made in staff. So I understand that staff here have eight weeks of solid training before they can join the front desk at Reception. Why have you made those very substantial investments?

KG: So we knew from customer owner satisfaction surveys what they wanted and what they wanted changed, and part of the change that our population wanted was how to be treated with respect, to be able to have say in their journey of our wellness and not be left out. Most employees that work with us are at the level of delivery of care, our doctors and nurses and proprietors in that way, and so our investment in our employees was meaningful again – just as it was towards building our building. The investment meant we were going to take employees that used to work for the government and then potential new employees and we had to set the tone for where and what they were going to do. We not only surveyed our customer owners about what they wanted. We asked employees, “What do you want? How would you like to be a part of the redesign? What would you like to see?” and gave employees options about those changes and then listened to what they had to say.

So we built means and ways for employees to be involved in every aspect of change within the organisation. How many employees or how many organisations have access to their leadership, the governance level and their CEO and their Vice Presidents with the ability to implement change within their own work environment? We didn’t ask them once. We ask them every year, “What is it we’re doing well?” listening to their feedback and then having them involved in the decision making process. We invest in employees so many ways. We provided infrastructure where they can see their measurements and their outcomes. It isn’t about asking employees to do something or achieve a mission and vision but we gave them tools on how to achieve the vision and mission so that every employee knows through a work initiative how they’re being able to do that, and then not stopping there, we keep giving data, we keep giving information back to them about what they’re achieving and how they’re achieving it.

BC: And finally Katherine, you’ve visited the UK, you know a little bit about our system. What would be the single most important piece of advice that you might give our leaders as they embark upon major transformations of their own?

KG: I would hope everybody has the same vision and knows how they’re going to achieve that through their mission and have all their leadership – whoever that is – in the room agreeing to it. For me, as you do organisational change, sustainability, paying attention, don't move from the direction you’re trying to go, back those successes as well as failures. I think feeding back to your population, your community about what you’re doing. When you go under construction and you walk into a building, there are signs everywhere and there’s signs that say, “Oops, we apologise but right now this place is under construction. Please bear with us,” and if your community doesn’t understand that you’re trying to effect change and that it’s going to take a while and they don't understand where you’re going, you lose that backing of those 65,000 voices that we have. But if they know, if your governance knows and your community knows what you’re up to, what you’re trying to achieve and you feedback little successes – even if it’s one or two or five things you heard your community say they wanted and you achieve those and you feed it back to them and your governance, the next time you ask your community, “Are you doing well? is there something else we can do?” They’re going to respond and respond and say, “We hear you. We hear you asking. We believe in you. We trust you, and we understand you’re under construction and it’s going to take time,” and then you have those moments of pause that you can have to do that reconstruction in a real good manner instead of trying to rush it, trying to change something quickly that might not work.

BC: Katherine, thank you very much.

KG: You’re welcome.

BC: So LaZell, you were one of the first Nurse Case Manager’s at Southcentral and you participated in redesigning your multidisciplinary teams. Tell me a little bit about those teams and who does what.

LH: The primary care provider is the one that is overseeing the team, helping to set the plan – they’re the ones that physically see customers when they come into clinic. If they have village assignments, they go out and visit their customers in the villages twice a year, and they’re also monitoring their data to make sure that their outcomes are where they should be. The Nurse Case Manager’s position and role – they are more behind the scenes and they are all co-located in a one area together, an integrated care team; so they sit elbow to elbow to each other. So they’re all within line of sight of each other. The Nurse Case Manager is doing population management; so they’re looking beyond just the customers that are presenting that day in clinic. They’re looking at their whole panel which ranges in size between 1,000 and 1,300 customers. So they’re looking proactively at the needs of their panel. They are looking at the day’s schedule and looking to see if there’s anything that we could do to max pack that visit and then they’re coordinating with the rest of the team to make the plan go smoothly for the customer.

So the Certified Medical Assistant, they’re in a role to the team as far as the… they’re the masters to be able to make sure the flow of the day goes well. So they are the person that is rooming the customer. So at the beginning of the day, our schedules look very different than midday because our goal is that when you look at our schedules across the board at 8am, 50% of our access is open for our customers so that we truly can deliver on same-day access. So they are looking at the schedule. They’re proactively setting the rooms up to anticipate the needs of that visit. They are managing the schedule – so as things change throughout the day, they’re able to inform the staff. So they are notified in our system, our EHR, that a customer is ready and has been checked in at our front desk and they physically go out to our lobby area and invite them to come back for the visit. As they’re coming back, they are doing vital signs – so they’re weighing them and getting their vital signs, and then they have some screening questions that we do for things like depression screening, and then they do their vitals in the room, enter them into the EHR, and then they notify the primary care provider that the customer is ready, and then they’re on about their day to plan for the next one or bring the next customer back.

BC: So how do these primary care teams work with the other specialist staff you have in your integrated care teams?

LH: If there’s someone that has a history of depression, the BHC or the Behavioural Health Consultant may have already looked at that schedule and looked for anything that might cue them into going in on that visit and so they’re already kind of prepared before they would go in on the known items that they would go in for. So the provider would go in after the CMA or Certified Medical Assistant has notified them, they go in, they would see the person and they would come out and tap on the Behavioural Health Consultant to let them know that they’re ready to do a warm hand-off to bring them in. That co-location has broken down so many barriers for us and it’s really built that dynamic of our teams that we are intending, and there’s some magic that happens in those integrated care teams because of that proximity.

So we have what’s called a data mall and it’s an online tool that has a gooey interface that people are able to access – readily access their data, specific to their panels – I mentioned our panel sizes are between 1,000 and 1,300 generally speaking. So you’re able to look at that data and say, “This is my data, these are customers that come to us to partner with for their care, and I’m able to reach out to them proactively,” and of that 12%, it lists their name, date of birth, if it’s a kiddo it lists who the guardian is and their phone number and so it makes it easy for me to do the right thing as a clinical person.

BC: So Ileen, throughout the Southcentral buildings, there are banners setting out your vision and your values. Can you tell me a little bit about the most important principles that guide your organisation and how they’ve shaped how you do your work?

IS: We knew that we needed to have something that the whole organisation as we move forward, could line up with. Everything that we did, we needed to have something that not only could our providers, our employees, what we’re going to say customer owners now, everyone could understand exactly where we were going, what we wanted to do and kind of what was that vision that we had and so that’s where we came with our vision, mission and our key points. And so vision is a native community is a native community that enjoys physical, mental, emotion and spiritual wellness so as a whole person. so we’ve always looked at the whole person, even back then. Today you hear people talking about that for healthcare but for native people, that was the core. We couldn’t just look at the physical because we’re more than that. So as native people, we look at the whole so that was critical. And then with the mission, it’s all of us working together in partnership. We knew we couldn't do it by ourselves. We would have to have partners that could link up with us in the different areas of need – including our customer owners or patients. It’s within our own region our other non-profits – Coconut Housing Authority, Coconut Tribal Council, the Justice Centre, all of those partnering together.

BC: So lots of organisations have mission statements and values. What do you do to embed those values in the organisation and make them meaningful? How do you use the values to change behaviours? 

IS: Okay. So you’re right – a lot of times you can get a vision and mission that’s up on the wall. For us, it has to be here. You have to grab that passion around what we’re doing to make a change. So one of the things we do is right at the get-go, as we are interviewing, we have a behavioural based interview. It starts there. How do you hire people? So you’re starting to talk about that already – what are the core values – even within that interview process. Does it match up with their personal values? And then we have core concepts – every employee will go through core concepts. We have a longer orientation as we bring people on-board. Again, it’s core that they understand what’s important to us before they even get on the floor and so core concepts is three days with our President CEO, with leadership at Southcentral Foundation, talking about how do we develop relationship? How do we communicate? How do we value one another? How do we understand that everyone has a story?

BC: In addition to customer ownership, you’re also built very strong links with your local communities. Can you tell me a little bit about how you’ve done it and why?

IS: It takes a long of communication. We do a lot of asking. A lot of different venues for asking. So one example is we used to do the paper surveys and you would get one three months after you had your appointment. Well a couple of years ago, we did a pilot with an iPad and tested it out at our annual gathering. At our gathering, we have about 3,000 to 5,000 people that come and see what we’re doing, about 150 booths of partners within the community, our programmes, we had food, fun, culture, native dancing and all of that. So it’s always going to be an opportunity to draw our people in, to have fun like we did at the picnic yesterday. Again, we want them touching our system. We’re drawing those people in that didn’t have confidence in the healthcare system and so we’re drawing them back in. But in doing that, if we’re going to ask and say, “What is that you want to see?” “We want same day appointment. We want our own primary care team. We want to be treated with respect.” And as we’re doing that, then we have to let them know that we went ahead and we’ve made this change. So there’s this whole communication and feedback loop that happens.

BC: So what advice could you give the providers in our National Health System on how they could place patients at the centre of how they change services?

IS: I think if you look at where you’re at. Look around your community and see who is… who are your customers really. Who is it that you’re serving? And I think that’s a place to start. Is there a way that you can – within those communities – bring people in and identify… maybe you identify just a group of people to come in and start conversation. And so you have to be willing to hear – especially at the beginning – what is not working and what do we want changed?

BC: So Melanie, you’re a customer owner here at Southcentral Foundation, but you remember the old system run by the Indian Health Service up until the late 1990s. Can you tell me a little bit about what you remember from those services?

MB: It wasn’t a friendly atmosphere. It wasn’t very clean. It was very rundown and it wasn’t very culturally orientated and they didn’t have family medicine back there so we had to go through the ER system and you had to wait and wait and wait and we were never treated as people, we were treated as a number, and you never knew when and who you were going to be seeing because of course it’s an Emergency Room – you always had the emergencies take higher priority and you never saw the same person twice of course, and then you could be there all night. You could be there until after midnight and, you know, it would be ten o’clock, midnight, one o’clock, two o’clock in the morning and I mean if you truly want to be seen, you wait there all night.

BC: Now across Southcentral, all of the staff I meet refer to what we would call their patients as customer owners. What does it mean to be a customer owner and why is this an important concept for you?

MB: I think it’s important because we own the system. Back in the day, we didn’t feel like owners. We didn’t feel like customers. We felt like just another number as I said, right? You didn’t feel like you had a say in what was happening, and as a customer owner, you have a voice. You have that opportunity to say, “This is what I want and this is what I need,” and you’re in partnership and a relationship with your provider and your provider team to say, you know, “I really don't think that’s going to work for me. Can we do something different?” And we have that discussion and figure out what’s the best plan to move forward. And again, it’s about ownership and responsibility. We took on the system in 1999 and said that we wanted to own it and I think we need people to say that we are the customer owners.

BC: So as the customer owner, can you really influence how services are delivered and where resources are spent in your system?

MB: Yes, I believe so. We have many different ways that we do that – through listening posts and through different voices in the departments but also our employees are customer owners, right? I’m a customer owner. I work in the organisation. I work in a position where I can help drive change and I can have those conversations with department leadership, executive leadership, senior leadership to say, you know, “We need to do something different or this is going well, we need to replicate this elsewhere,” and really have that voice to make that change.

BC: How have customer owners really changed how services are delivered?

MB: So again, the services… we listened to the customer and we heard what they had to say and so we implemented many different programmes across our organisation – traditional healing’s one of them. Tribal doctors – they’re working hand in hand with our primary care providers. So again, western medicine with traditional medicine. We have a traditional healing guardian that they can easily have that conversation with customers to say, “Here’s some other ways to think about doing healthy things.” We also have the RAISE Programme. We have a tobacco-free campus. We were the one first of the facilities or hospitals in the Anchorage area to go tobacco-free on campus. 

BC: And these were all ideas that came from customer owners?

MB: All that came from customer owners, and that feedback that we have and our listening posts and everywhere that we can hear, we’re listening and we do what we can.

BC: Sarah, you’re an English national, a GP who was trained and then worked in the NHS. Can you tell the folks back home what’s fundamentally different about working as a Family Doctor here in comparison to being a GP in England?

SD: The model of care delivery is very different here. We have the whole structure of… I work as a member of a team which is very different from anything I’ve done in Britain, and we’re right next door to the hospital so referrals and working with our colleagues in the hospital is fundamentally different here to anything I had in Britain. In the NHS, I worked in my own little room and people came in to see me and at the end of the morning, I would sigh and rush out and have a whole massive paperwork and try and delegate a few things. Whereas here, I do everything as I go along. So my team involves my Scheduler, I have a Medical Assistant – something called a CMA – who brings the patients into my room and measures their vital signs, and I have a Case Manager and I think the Case Manager’s absolutely vital to everything I do and she is central to my life. So that’s my own personal team, and then I’m part of a bigger team.

We work in a clinic and in the clinic, there’s a Pharmacist. So if I have questions about medication, I can go there straightway and he’ll hope with dosing and side effects and medications. So that’s incredibly helpful. We have a Dietician and with the problems with Diabetes and Dietary issues, we can call on them immediately after I’ve seen a patient or a customer owner and we have a Behavioural Health Consultant – a kind of a Counsellor – and as we all know, most… a lot of medical problems have a psychological basis so it’s incredible being able to call on that person after a consultation because I think it’s important to do things immediately and if you refer someone and they have to wait for several weeks or months, that problem has gone.

BC: Now you know both systems. Do you think that the model of care that’s been developed here could be easily transposed to the English system?

SD: I think there are ways that it could be used, but I think it would pretty difficult to actually transpose it completely because the way that patients are seen are very different. In Britain, patients come in to see the doctor. Whereas here, the doctor goes in to see them and because the doctor goes in to see the patient, they then take their work back into the communal room to finish it off and write up their notes, their charts, and when you’re in that environment, that’s when you actually go out and you use… you find the support staff. That’s when I find my Behavioural Health Consultant. That’s when I find the Dietician. That’s when I speak to my Case Manager. So it’s that immediate feedback after seeing the customer owner that we don't have in Britain that is vital and I think essential to the work that we do here and I don't know how one could do that in Britain when you just have ten minutes per patient.

BC: So I guess what you’re telling us is if we want to adapt the system, we need to make some pretty fundamental changes.

SD: I think that’s right. Yes.

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.

BC: Now your mission statement focuses on the concept of wellness rather than treating diseases.

DE: Right.

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.