Integrated Primary Care Teams Transform Alaska Native-Owned Healthcare System
Southcentral Foundation (SCF), an Alaska Native-owned healthcare system, has taken an integrated care team approach to primary care. In a recent webinar, SCF clinicians described how they build and maintain these teams.
SCF is responsible for providing healthcare and related services to approximately 65,000 Alaska Native and American Indian people in southern Alaska. SCF’s Nuka System of Care is a relationship-based, customer-owned approach to transforming healthcare, improving outcomes and reducing costs. The organization says the model keeps everyone in the system on the same page when it comes to a customer-owner’s care, and makes it easier for customer-owners to navigate the system.
During an Aug. 5 webinar hosted by the National Center for Complex Health and Social Needs, Chelsea Ryan, a registered nurse case manager, and Steve Tierney, M.D., senior medical director of quality improvement, described the work flow and collaboration changes put in place by SCF.
Ryan began by talking about some of the advantages integrated care teams offer compared to the more traditional, provider-centric method of providing primary care.
The teams are made up of a primary care provider, registered nurse case manager, certified medical assistant, case management support, and other providers as needed by the customer-owner.
“We realized that previously our workflow was very provider-centric,” explained Ryan. “All roads led to a provider where all decisions had to be made, whether it was preventative care, chronic disease management, acute complaints, following up on lab results or medication refills. That leads to a bottleneck; it means that there's going to be longer wait times for the customer, there are going to be balls that are dropped, there is going to be an overall sense that we are putting out fires, because what we're doing is inefficient.”
She said the team recognized that this wasn't the best way to deliver care and it wasn't sustainable to continue working in that fashion. Since moving to a more team-based approach to primary care, she said, there's a greater sense of interconnectedness, interdependence, and collaboration. “There's a whole bench there to support a customer-owner and supporting a provider in delivering care.”
Ryan explained that besides a deep understanding of Alaska Native values and traditions, continuity is a really important concept in the way that the healthcare system is built. “We provide continuity for our customer-owners systematically through a process called empowerment. That just means that each customer-owner at Southcentral Foundation is assigned a relationship to an integrated care team,” she said. “That is their touchpoint in the system. It's where they go with questions. It's where they come in for all of their care, and this has really been critical for us. We got to this place based on feedback from our customers and from our staff. Our customers no longer wanted the old model of healthcare delivery in which they went to the emergency department because they didn't have primary care and going in for medical treatment meant that they could expect to go for a full day. It didn't work for our customers to continue coming in and seeing somebody different every time and having to tell their story over and over again. Developing this process and saying continuity matters has really transformed the way that we operate. We found that it creates trust between customers and the team when they can get their needs met without jumping through hoops. Customer-owners have direct phone numbers for their RN case manager. If they show up at the front desk without an appointment, somebody is going to greet them, and they can reach out through a secure online messaging portal.”
Each primary care team has about 1,100 to 1,400 impaneled customer-owners. That primary care team is the medical home for the customer owner, but there are additional layers of support that SCF has learned are necessary to promote high-level care. “In each clinic, we have integrated pharmacists, we have behavioral health consultants, and we have a registered dietician and a certified nurse midwife,” Ryan said.
Tierney said the way they have organized the teams allows everyone to work at the top of their license and keeps the physician from being the bottleneck anymore.
He noted that about 40 percent of customer-owners actually have pretty straightforward needs, and the RN case managers can keep an eye on all their vaccines, cancer screenings, prescription refills and lab values. Another 40 percent of folks have fairly stable but well-controlled chronic conditions such as diabetes, heart failure, hypertension or asthma. “What they need is monitoring and prescription refills — and if it does go sideways to get in the door here very quickly rather than going to the emergency room. That way, we can actually spend most of our high-end, expensive, rate-limited clinician time on people who aren't doing well, because that's who needs us,” Tierney said. “And they need to see somebody who knows them well. Now, when you walk in the door and you see me, if I need to, I can go get a behavioral health consultant, pharmacist, midwife, or community services specialist." It no longer requires a referral. Those providers are just down the hall, he said.
Ryan also stressed the importance of including family members in the equation. “One of the Alaska Native cultural values is that we are a very communal people; we're not individualistic,” she said. “It is not uncommon that family members are very involved as a critical piece of the puzzle that makes up customer wellness. We welcome that into the way we deliver care.”
