Abstract
In the 1990s, Alaska Native people chose to assume responsibility for their own health care and transform the system to provide better care than they had received as “beneficiaries” of a government-run system that did not meet their needs. Southcentral Foundation (SCF), an Alaska Native-owned and managed organization, took responsibility for providing primary care and related services to Alaska Native and American Indian people in Alaska’s Cook Inlet region. Upon doing so, they worked directly with the Native community to ensure that the health care system would address their needs and reflect their values.
Among the most important things the community identified for the health care system was being able to choose their own provider (something Alaska Native people had not been able to do under the previous government-run system), being able to see their chosen provider whenever they needed to, and having input into their care decisions. To support these goals, SCF established Integrated Care Teams to provide primary care services. The core Integrated Care Team consists of a primary care provider, nurse case manager, certified medical assistant, and case management support. Additional care workers such as dieticians, pharmacists, and behavioral health consultants can be added to the care team as they are needed. All members of the care team form relationships with customer-owners (SCF’s term for patients), which enables them to understand each customer-owner’s unique story and more effectively support them in achieving wellness.
To chronicle SCF’s efforts at building Integrated Care Teams, and to provide insight on SCF’s successes and lessons learned, SCF has created the Integrated Care Teams Playbook, a step-by-step guide for health care organizations to build their own Integrated Care Teams. The playbook documents many different aspects of SCF’s care teams, including team composition, roles and responsibilities, empanelment of customer-owners, access, referrals to specialty care, and much more.
In part due to SCF’s implementation of integrated care teams, SCF saw a 44% decrease in ER visits in the five years after the system transformation, as well as a 63% decrease in hospital discharges during that same time period. SCF ranks above the 75th percentile in many health outcomes for customer-owners as measured by the Healthcare Effectiveness Data and Information Set (HEDIS). 97% of customer-owners are satisfied with the care provided by SCF, and SCF has also achieved 91% employee satisfaction.
SCF’s experience shows that by building systems of integrated relationship-based care, health outcomes and satisfaction rates can be improved. And SCF’s Integrated Care Teams Playbook provides a blueprint for other organizations to use to implement their own Integrated Care Teams. This session will be held in an interactive lecture format, with participants divided into small groups. The presenters will periodically include breaks for the groups to discuss the material presented, and the smaller groups will report out to the full session so that a variety of perspectives can be shared. Every attendee of this session will receive a free digital copy of SCF’s Integrated Care Teams Playbook to take back to their own organizations.