Patient engagement reimagined has driven a new value-based care delivery model supporting population health in Alaska Native and American Indian peoples.
At Alaska’s Southcentral Foundation, a patient is not a patient. She’s a customer-owner, and through an innovative patient engagement and care delivery system, she knows she’s in charge of her own care.
The healthcare organization, which is home to the Nuka System of Care, delivers health and wellness services to Alaska Native and American Indian patients living in the Anchorage area, the Matanuska-Susitna Borough, surrounding villages, and 55 remote villages across the 107,400 square miles of Southcentral Alaska.
And it’s that very Nuka System of Care that allows SCF to effectively treat those customer-owners. The Nuka System of Care is self-described as a “relationship-based, customer-owned approach to transforming health care, improving outcomes and reducing costs,” SCF says on its website. It has twice received the Malcolm Baldrige Performance Excellence Award out of the National Institute of Standards & Technology (NIST), and is largely responsible for a near-total transformation of Alaska Native and American Indian healthcare.
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According to April Kyle, a 17-year veteran at SCF and current Nuka System of Care interim CEO, Alaska Native and American Indian healthcare has deep historical roots. As sovereign governments, Alaska Native and American Indian peoples entered into treaties with the US government in response to early colonization and the negative consequences that held.
“One of those treaties resulted in a settlement in exchange for the lands and resources lost by Alaska Native and American Indian people where the government would provide healthcare and education to Alaska Native people, American Indian people in perpetuity,” Kyle said in a keynote address at Xtelligent Healthcare Media’s Payer+Provider Virtual Summit, The Return to Value.
“When that happened, the US government did what you would imagine. They set up a branch of the government called the Indian Health Service,” Kyle, who is of Athabaskan descent and a customer-owner herself, continued. “They started operating hospitals and clinics and delivering services. And as a kid, I received my healthcare in the old Indian Health Service hospital which was in downtown Anchorage and it was a woefully underfunded system.”
Although Kyle said the old IHS hospital was staffed by wonderful workers, it was beleaguered by the constraints of traditional US medicine and was unable to deliver true population health management.
It wasn’t until 1975 when Congress passed the Indian Self-Determination Act that Alaska Native and American Indian peoples saw a transition from government-led healthcare to appropriated healthcare dollars. The US government took the funds it would have otherwise invested in the old IHS facilities Kyle visited as a kid and let Alaska Native and American Indian peoples themselves develop their own models of care.
That led the Alaska Native and American Indian people in the Anchorage area to deep community introspection, conversations with non-medical lay people, and a broad formal and informal community analysis to determine how best to meet people’s mind, body, and spiritual needs.
And from that, the Nuka System of Care was born.
REIMAGINING THE PATIENT AS A HEALTHCARE STAKEHOLDER
According to Douglas K. Eby, MD, MPH, CPE, the vice president of Medical Services at SCF, the US medical system operates with two fundamental problems. The first relates to payment incentives and the private insurance sector, a problem SCF cannot entirely circumvent with the Nuka System of Care.
But it can address the second problem: paternalistic and hierarchical relationships between patient and provider.
“Even when payers are not the problem and payment incentives are not the problem, you still find this blind allegiance to the medical model, which is completely ridiculous and largely ineffective for population health in getting to wellness,” explained Eby, who joined Kyle in the keynote address.
“The medical model sees the body made up primarily of parts and sort of like a machine. And you have centers of excellence of specialists and sub-specialists who emphasize different parts of the body. And it pretends that if you just get all the parts of the body working well, that somehow health and wellness will follow, and that’s just not true.”
The medical model Eby refers to also contends that patients need to engage in health and wellness on healthcare’s terms—come into the clinic or hospital, follow its norms, and then the patient will be healthy. Again, that’s just not how things shake out, Eby asserted. A clinician can push the patient toward what she believes is health and wellness, but the patient will ultimately go wherever and do whatever is amenable to her.
The Nuka System of Care turned that paradigm on its head by not thinking of those it serves as patients or consumers, but as customer-owners. After all, as a member of an Alaska Native and American Indian tribe receiving US government funds as part of treaties, they are in fact health system owners.
But that verbiage is about more than just semantics, Kyle and Eby agreed. It’s about partnership and empowerment.
“One of the key changes we made was being very intentional about how the healthcare system is oriented in relationship to Alaska Native people,” Kyle explained. “In our system, we don’t say patient or client or consumer or member, we refer to the Alaska Native people as our customer-owners. It reminds me as an employee that when a customer-owner wants to meet with me, that person, that family, they own it. They own the camera that I’m looking at right now, the building that I’m sitting in, my paycheck, how we organize the organization. Everything about what we’re doing is owned by them.”
That’s empowering, Kyle suggested, and leads to important partnerships.
Those partnerships are essential to effective population health management, Eby added. The traditional medical model suggests a patient is a passive being that will simply heed the advice directed from the provider.
“And this is the great fallacy of the medical model,” Eby stated. “We think if we give [patients] an accurate diagnosis and treatment plan, magically they will comply. And when they don’t, in our judgmental, paternalistic, horrible way we call them non-compliant. It just does not work.”
This mindset of the patient as a customer-owner has informed the entire care delivery model at SCF, culminating in the Nuka System of Care. Operating under the principle that patients are true, engaged partners in their care—hence the phrasing of customers and owners—the Nuka System of Care needed to diverge from traditional delivery models.
“A manufacturing model works when the patient or the customer-owner is passive,” Eby said.
But the customer-owners at SFC are not passive, and that means they need something other than a manufacturing medical model.
“When they’re active, it needs to be a service model,” Eby said. “Meeting them where they are, giving them choices and acknowledging that they’re in control.”
HOW THE NUKA SYSTEM OF CARE DELIVERS HEALTHCARE AS A SERVICE
The Nuka System of Care has seen tremendous success. The two-time Malcolm Baldrige awardee can boast low high-acuity utilization, low emergency department and hospital use, low specialty care referrals, and total costs well below the national average.
SCF has 2,500 staff, with partners at the Alaska Native Tribal Health Consortium bringing it to a 3,000-person staff working in the medical field.
“And between us, we are vertically integrated across everything from community to intensive care units,” Eby explained. “Our population used to be in the bottom fifth percentile in almost all measurable health outcomes and now we are in the 75th and 90th percentile in almost all of our health outcomes as compared to national HEDIS benchmarks and our satisfaction levels for people both receiving services and working for us are very high.”
“So it’s the true triple aim and what everybody in healthcare says they want,” he added.
This level of success comes from more than just a principled vision; through the Nuka System of Care, SCF has an extremely efficient care delivery model that allows them to deliver on customer-owner needs.
The Nuka System of Care means SCF provides immediate same-day access to customer-owners, who are people with deep, long-standing relationships with their organization. These folks are surrounded by primary care physicians, dieticians, medical assistants, caseworkers, behaviorists, midwives, pharmacists, and a litany of other clinical staff.
These providers are co-located, meaning they work in the same physical space as a part of SCF’s work to de-office clinicians. And because specialists don’t have their own schedules or caseloads, they can work directly with generalists.
“The mind and body are together and complexity is handled right in primary care because all of these people are immediately present and available to support you, again, whether virtually, synchronously, asynchronously, or however people want to do it,” Eby noted.
From a financial perspective, SCF gets paid the same way any other provider organization does—it is still a provider within the US healthcare industry, which means it’s beholden to payer contracts, fee-for-service arrangements, and public payers like Medicare and Medicaid. SCF also gets 40 percent of its payments through the government treaties Kyle mentioned.
But the care delivery model hasn’t led SCF to hemorrhage money; in fact, quite the opposite. As Eby noted, SCF’s costs are lower than the national average.
This all works because they are not adding or subtracting from the traditional model of care. In Eby’s words, they are rearranging that traditional model of care. For example, SCF may not employ more dieticians than a similar organization using a different care delivery model, but the team-based care has proven cost-effective.
The organization also sees a massive return in investment in how it structures primary care because there are far fewer expensive referrals to specialty care. Remember, specialists work as part of the co-located care team, informing generalists and creating a more well-rounded generalist experience.
“So by practicing the way we practice, we may lose tens of millions in revenue that we would otherwise be making if we practiced in the usual way,” Eby explained. “But we’ve probably decreased our costs also by tens of millions by not doing a lot of things that are very expensive and running the waste and stupidity out of healthcare.”
As noted above, all of this became possible by the 1975 Indian Self-Determination Act. That piece of legislation created the permission structure for Alaska Native and American Indian tribes to create change that suits their community health needs, Kyle said.
“[Congress] said that if the people have a voice in their system, or better yet are in control of and can lead their own healthcare, then the people’s health outcomes could improve,” Kyle explained.
“And it was a massive undertaking and those conversations about whether the government should operate healthcare, should our communities operate it, and what does that look like, continue to happen.”
Laying the groundwork for this is the idea of change. This is not a new concept in healthcare. Innovation is at the heartbeat of everything any provider does.
But for SCF, change meant something more fundamental.
“A lot of folks think about change,” Kyle said. “And what they really mean is ‘we’re accepting the norms in the model in whole and we’re tinkering around the edges,’ right?”
The Nuka System of Care is not the norm in the traditional healthcare model, Kyle asserted. It is healthcare reimagined to meet the needs of communities, families, and customer-owners.
SCF is still going through a state of change, Kyle added. By consistently partnering with customer-owners, the healthcare organization understands that its evolution never ends.
“And our journey is moving from the hospital at the top, which was not at all meeting our community’s needs, to a much more robust community-led healthcare system on the bottom of this slide that continues to listen to customers, innovate, hear what people need, change again,” Kyle said. “And that constant feedback loop means that our job is to forever know what our community needs and to evolve towards those needs as we continue.”
Source: Patient Engagementhit