nuka! south central foundation of care

M20: Beyond Patient Centered Medical Home - SCF

Nuka System of Care, Improved Overall Outcomes

Katherine Gottlieb, MBA, DPS (h.c.), President/CEO

Douglas Eby, MD, MPH, Vice President of Medical Services

Presenters have nothing to disclose

Copyright © 2011 Southcentral Foundation. All Rights Reserved.

NOTICE: Unless otherwise indicated, this work represents copyrighted material protected by United States and international law.

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�Powerful tool used to kick off dialogue

�Each participant in the dialogue has an opportunity to speak for a moment about what they are thinking or feeling while others listen in silence

�Time to “check into” the dialogue

�Use at beginning, end or a difficult times during a dialogue

Check In


� Introduce yourself at your table and discuss how you are doing today

�Discuss what are you hoping to learn today

�TIME – 10 minutes

Check-in

3Copyright © 2011 Southcentral Foundation. All Rights Reserved.

� Review the transformational journey of an entire healthcare system from physician centered to patient centered to customer-owned

� Understand the systematic approaches to creating and sustaining ongoing relationships between a customer-owner and physician that go beyond access and communication

� Understand the necessary requirements for moving beyond a patient centered medical home to a customer-owned healthcare system including the approach to: leadership, workforce, data, listening and responding to customers and the community, and healthcare delivery

Objectives


Katherine’s Story


�Discuss how you connected with Katherine’s story and/or how did Katherine’s story impact you.

�Time: 10 minutes

Check In


�Knowing one another in a deeper, more meaningful way, provides a richer, more meaningful work environment.

� Sharing stories helps create a place where there is value in relationship, where we value our customers

�Our stories are an important part of who we are (and who our co-workers and employees are)

The Importance of a Story


�A record or narrative description of past events

� Sharing of story is done to show values, pass on skills, and in some instances show why and how something is or came to be

What is Story


�A story can be shared at various levels or depths• 30,000 foot – i.e. What happened while you drove to

work• 10,000 foot – i.e. A difficult situation getting along

with coworkers or a friend• Ground Level or Below - i.e. A profound moment or

memory that affects you today

Levels of Story


SCF Board of Directors


Vision A Native Community that enjoys physical, mental, emotional and spiritual wellness

MissionWorking together with the Native Community to achieve wellness through health and related services


Key PointsShared Responsibility

Commitment to QualityFamily Wellness


Relationships between customer-owner, family and provider must be fostered and supportedEmphasis on wellness of the whole person, family and community

(physical, mental, emotional and spiritual wellness)Locations convenient for customer-owners with minimal stops to get all their needs addressedAccess optimized and waiting times limitedTogether with the customer-owner as an active partnerI ntentional whole-system design to maximize coordination and minimize duplicationOutcome and process measures continuously evaluated and improvedNot complicated but simple and easy to useS ervices financially sustainable and viable Hub of the system is the familyI nterests of customer-owners drive the system to determine what we do and how we do itPopulation-based systems and servicesS ervices and systems build on the strengths of Alaska Native cultures

Operational Principles


Government recognized that:

If the people receiving the health service are involved in the decision making processes, better yet, if they own their own health care – programs and services have a potential for enhancement and the people and their health statistics will improve.

Indian Self-Determination and Education Assistance Act 1975


Alaska

At 591,000 square miles, Alaska is as wide as the lower 48 states and larger than Texas,

California and Montana combined.

San Francisco

Charleston


1982 - Fewer than 100 employees and budget of $3million

2013- 64,000 customer-owners; 1,600 employees; budget $227million

Customer Ownership


� 64,000 Customer-owners

• 54,000 Anchorage and Valley

• 10,000 55 villages

� Employees• 1982: Fewer than 100

• 2013: About 1,600

�Operating Budget• 1982: $3 million

• FY 2013: $227 million

From 1982 to 2013…

Operating Budget

1982 FY 2013

$3m

$227m


� Primary Care

� Dental

� Behavioral Health – Outpatient

� Behavioral Health - Residential

� OB-GYN

� Health Education

� Elder Program

� Co-manage 15 bed hospital (ANMC)� Complementary Medicine� Nilavena Subregional Clinic� Radiology, Laboratory, Pharmacy� Audiology

� Emergency Department � Home Based Services � Optometry� Traditional Healing � Family Wellness Warriors� Infrastructure/Support

SCF Programs and Services


� Office of the President• Divisional structure

� Executive and Tribal Services, Medical Services, Behavioral Health, Resource and Development and Organizational Development and Innovation

• Line Authority

� Functional committee structure • 4 areas of focus to get to high performance

� Operations– effective day to day operations

� Quality Assurance– compliance with standards etc.

� Process Improvement– improving systems and structures

� Quality Improvement– improving clinical and educational services

Organizational Structures


Why Listen to Our Story


� Utilization• 75% decrease in hospital admissions since 1999

• 71% decrease in hospital days per 1000 since 1999

• 36% decrease in outpatient visits per 1000 customer-owners

� Clinical quality• Level 3 NCQA Patient Centered Medical Home

• 75 or 90 percentile for HEDIS outcome measures o Diabetes

o Cancer

o Cardiovascular disease

Measures of Success


� Customer-owner satisfaction• Overall 93%

� Employee satisfaction• Overall 94%

• Response rate 83.2%

� Employee Turnover • 10.8%

� Baldrige National Quality Award - 2011

Measures of Success



Doug’s Story:


�Discuss how you connected with Doug’s story and/or how did Doug’s story impact you.

� Time: 10 minutes

Check In


�Medical care is too big and too complex with way too many services, agencies, and offerings to be left uncoordinated and without a strong navigator/coordinator role

�Doctor-centric Medical Model primary care has failed – need to rethink everything

� Poor ‘primary care’ = ineffective system

� Current model actually does HARM

Primary Care needs changing


� Limited capability if fundamental platform is not rethought

• Think like a business, managed care, safety

• Case Management 2002-2007

• Then – Six Sigma, TPS, flow, reliability, spread, bundling, P4P, E.H.R

• Now - PCMH, ACO, Affordable care, single payer

Previous Healthcare Fixes - USA


� The PCMH 2011 program’s six standards align with the core components of primary care

• PCMH 1: Enhance access and continuity

• PCMH 2: Identify and manage patient populations

• PCMH 3: Plan and manage care

• PCMH 4: Provide self-care support and community resources

• PCMH 5: Track and coordinate care

• PCMH 6: Measure and Improve performance

PCMH Criteria

�Medical Model – not questioned

� Each piece of healthcare optimizing their financial position – very sophisticated financially and bankrupting society

�Better, faster, safer version of what we have – no fundamental change

The result of previous fixes


Who really makes the decisions?

Acuity

“Control”

0Low High

100%

1. Control – who makes the final decision influencing outcome?2. Influences – family, friends, co-workers, religion, values, money3. Real opportunity to influence health costs/outcomes – influence on the choices

made – behavioral change4. Current model – tests, diagnosis, treatment (meds or procedures)


� If you are in a mechanical, manufacturing environment then hitting a target it a matter of throwing a rock – figuring out speed, trajectory, etc.

� If you are in a messy, human, complex, adaptive environment – it is like throwing a bird at a target – it is all about the ‘attractor’

Hitting the target…


Hitting Target: Rock vs. Bird


Low Highcomplexity -variables

Complexity

Low

High

Cert

ain

ty o

rA

gre

em

en

t

Protocols & Stds

ChaosExperimenting

Get together and have dialogues

An allowing/positive

environment

Multidimensionalimprovements with

target focus Creativity

complexity diagram

Some simple rules for improvement


�Health is a longitudinal journey• Across decades

• In a social, religious, family context

• Highly influenced by values, beliefs, habits, and many ‘outside’ voices.

�Office visits are brief, reactive stop-gaps

�Hospitalizations are brief, intense interruptions

�MUST fix basic, underlying primary care platform first or nothing else will work well

Reality


�We are a Service Industry – NOT a product industry –coaching, teaching, partnering are central – pills and procedures supportive

� Changes what we think we do, who we hire, how we train, how we structure, how we reward, and how entire system is constructed as a system.

�We must optimize relationship – personal, trusting, accountable – minimize barriers

Purpose of Primary Care


�Why not take the best known practices and design a system?

�Why not spread this system everywhere and reap the benefits?

�Why has this not already occurred?

�Why is this so hard?

Just Do It… Why not?


�Unquestioning belief in the medical model and professionalism

�Firm basis in science, technology, industrial manufacturing models, body as physical

�Many people making a whole lot of money in current system – as independent pieces

�Current system allows/supports/rewards independence and entrepreneurial thinking – no common purpose, framework, principles

�Very weak workforce and management theory, knowledge, skill in healthcare

Difficulties



�Unfriendly and rude staff

�Guinea pig for new doctors

�Customers waited for everything• Long waits for scheduled appointments

• Four- to six-hour waits common Long waits on phone, pharmacy, everywhere

� Inconsistent treatment

�Risky place to go

The Drive to Change


�Customers frustrated – waiting, impersonal, paternalistic, crowded, unfriendly

�Clinical staff frustrated – too many people, not enough time, no personal relationships, too many demands

�Management frustrated – lots of unhappy people, hard to motivate staff, poor financial performance, challenging facilities

Everyone Was Frustrated …


�Discuss what you would change in your healthcare system if you owned the healthcare system.

�Time: 10 minutes

Check in


� Southcentral Foundation uses the term customer-owner instead of:

• Patient

• Client

• Customer

Customer-owner


Questions


� Our vision

� Shared Responsibility

� Operational Principles

� Core Concepts

� Board of Directors

� Role model

� National, regional and local partners

� Functional Committee Structure

Leadership - Key Improvements


Leadership Development

� New Manager Orientation� Self led, 90 day completion, includes meeting with CEO

� Leadership Readiness• Comprehensive (360’s, CDRs)

� Leadership Development Sessions• Facilitated by CEO day-long sessions

� Executive Leadership Experience Training Program

� Special Assistant Training Program

� Development Center Courses


Core Concepts � Three-day training, ALL

employees

� Led by SCF President/CEO

� Build and sustain healthy relationships

� How we impact others

� How to articulate story from your heart

� Partnered with Society for Organizational Learning to develop


Workforce Core Concepts- Key Improvements

Work together in relationship to learn and grow

Encourage understanding

L isten with an open mind

L augh and enjoy humor throughout the day

Notice the dignity and value of ourselves and others

Engage others with compassion

Share our stories and our hearts

Strive to honor and respect ourselves and others


� Mission, Vision and Key Points

� Relationships across the organization

� Customer-owner input

Strategic Planning - Key Improvements



LinkagesEVERYTHING TIES TOGETHER!


SCF Strategic Planning Cycle


� Family Wellness (FMW)We value the family as the heart of the Alaska Native Community. We work to promote wellness that goes beyond absence of illness and prevention of disease. We encourage physical, mental, social, spiritual and economic wellness in the individual, the family, the community and the world in which we live.

• FMW1. Reduce the rate of Domestic Violence, Child Abuse and Neglect.

• FMW2. Reduce the rate of and improve the management of cancer.

• FMW3. Reduce the incidence of suicide.

• FMW4. Reduce the rate of obesity.

• FMW5. Reduce the rate of substance abuse.

• FMW6. Reduce the rate of and improve the management of diabetes.

• FMW7. Improve oral health.

• FMW8. Reduce the rate of and improve the management of cardiovascular disease.

Corporate Objective Example:


�Operational Principles

�Customer-owner in control

�Design of our work processes – team based

� Improvement Model –PDSA and Baldrige

Operations Focus- Key Improvements


�Advanced Access – appointments when the customer-owner wants – same day primary care

�Max Packing

� Interdepartmental Service Agreements

�Hospitalists in Pediatrics and Internal Medicine



�Microsystem Optimization -teams• Primary Care: Physician, RN, Certified Medical Assistant,

CM Support, Behaviorist, Dietician, Pharmacist, office redesign

• Behavioral Health teams: Physician, Master Level Therapist, Case Manager

• Human Resources teams: HR Generalist and Assistants –Same day service, etc.

�Home Health, Nutaqsiivik, Waiver Care Coordination, Home Visiting Physician



� Traditional Healers – Tribal Doctors

� Complementary Medicine –Chiropractors, Massage Therapists, Acupuncture

� Behavioral Health Redesign

� Facilities and work areas

� Family Wellness Warriors Initiative



Adverse Childhood Experiences

� Kaiser Permanente and Centers for Disease Control

� Over 17,000 participants

� Types of childhood trauma studied (ACE):

� Physical abuse

� Emotional abuse

� Sexual abuse

� Household alcohol / drug abuser

� Incarcerated household member

(ACEStudy.org)

� Mother treated violently

� One or no parents

� Divorce

� Emotional or physical neglect

� Parent who is mentally ill, depressed, or suicidal



� One type of ACE nearly doubled the risk of perpetrating domestic violence as an adult

� Four or more ACEs was associated with five times greater risk for domestic violence as an adult

• Physical abuse

• Emotional abuse

• Sexual abuse

• Household alcohol / drug abuser

• Incarcerated household member

• Mother treated violently

• One or no parents

• Divorce

• Emotional or physical neglect

• Parent who is mentally ill, depressed, or suicidal



� Exposure to one type of ACE increased risk of suicide attempt by two to

five times

� Exposure to seven or eight ACEs

� Increased risk of suicide attempts by 51 times during adolescence

� Increased risk of suicide attempts by 30 times in adults

• Physical abuse

• Emotional abuse

• Sexual abuse

• Household alcohol / drug abuser

• Incarcerated household member

Dube SR, Anda RF, Felitti VJ, Chapman DP, et al. Childhood abuse, household dysfunction, and the risk of attempted suicide

throughout the life span: Findings from the Adverse Childhood Experiences Study. JAMA. 2001;286:3089-3096.

• Mother treated violently

• One or no parents

• Divorce

• Emotional or physical neglect

• Parent who is mentally ill, depressed, or suicidal


Video


�Discuss how the video impacted you and/or how you connected with the video.

� Time: 10 minutes

Check In


� Governing board

� Advisory committees

� Elders Council

� Focus Groups

� Annual Gathering

� 24- hour hotline

� Community gatherings

� Personal interaction with employees

� Satisfaction surveys

� Comment cards

Customer Focus- Key Improvements


� Interview /Hiring

� Onboarding (ASTP, etc)

� Leadership development

� Development Center

� Career Ladders

� Job Progressions

� Mentoring

� Employee Wellness

Workforce Focus- Key Improvements


Would You Like to Live in Alaska?


Are You Sure?


� Training center

� Annual reorientation – reaffirm core philosophy (online & manager led components)

� All staff meeting (annually)

• CEO led session

• Peer teaching on topics chosen by employees

� Departments of learning based on workforce competencies

• More than 150 course offerings

• Partnership with university to award college credits

• Partner with other learning organizations to develop trainings

• Courses designed on adult learning theories including experiential learning

• Instructional designers partner with subject matter experts to develop training

� Internships (RN, Behavioral health clinicians)

� Scholarship program

Development Center


Data and Measurement- Key Improvements

� Multiple levels

� Mission, Vision, Key Points

� Data experts

� Data and sharing story

� Data Mall


Information to Knowledge

% Employees with Current Annual Disaster Tng

53

74

94 98 100

0

50

100

2005 2006 2007 2008 2009

%

SCF Industry Best (100%)


70

Then and Now …


Then and Now …


� No longer a hero but a partner• Control does not equal compliance

• Replace blaming with understanding

• Give customer options, not orders

• Provide customer with resources

• Make it simple

Health care provider changes


� Be active, not passive

� Take responsibility for your health

� Get information about your health

� Ask questions about advice

� Ask for options

Customer-owner changes


� Core Concepts – WELLNESS

� Role model

� Willingness to share story

� Willingness to hear story

� Admit mistakes

Leadership Changes


Questions


�What are you going to change or what can you change when you go back to your organization?

Check Out


It’s All About Customer-ownership and Relationships


Thank You!

QaĝaasakungAleut

QuyanaqInupiaq

Háw'aa Haida

‘Awa'ahdahEyak

Mahsi'Gwich’in Athabascan

IgamsiqanaghhalekSiberian Yupik

Tsin'aenAhtna Athabascan

T’oyaxsmTsimshian

GunalchéeshTlingit

QuyanaYup’ik

Chin’anDena’ina Athabascan

QuyanaaAlutiiq


nuka! south central foundation of care

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