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I Saw Primary Care Future And Its Name Is Nuka System Of Care

Today we run a piece from our archives to show you why PCP loves Southcentral Foundation, an Alaska Native-owned, nonprofit health care organization and the recipient of the 2011 Malcolm Baldrige National Quality Award for health care. Read about it here and then join us tomorrow night in Boston when Katherine Gottlieb, CEO, and Doug Eby, Vice President of Medical Services at Southcentral Foundation, speak at the Tosteson Medical Education Center Auditorium.  Details and RSVP on our homepage.

By David Margolius, M.D.

On May 22, 1974, music critic Jon Landau famously scribed a concert review about an unknown artist named Bruce Springsteen. After chronicling his nearly impossible hope that he could once again be completely consumed by rock and roll, Mr. Landau penned the quotation that would be credited for tipping Bruce Springsteen into stardom, “But tonight there is someone I can write of the way I used to write, without reservations of any kind. Last Thursday, at the Harvard Square Theatre, […] I saw rock and roll future and its name is Bruce Springsteen.”
 
Shortly thereafter, Jon Landau quit the critic business, became Springsteen’s manager, and the rest is history.
 
Almost 37 years later, I, too, hold a nearly impossible hope: That a primary care system can deliver team-based, customer-centric services to an entire patient population, in a way that allows quick access to care, facilitates relationships between patients and primary care team members, and takes place in healing environments. That’s the hope, but despite talk of team-based care and patient-centered medical homes, we’re not there yet.

Today’s primary care providers’ version of teams too often means delegating tasks to support staff (“go room my patient”), instead of delegating care responsibilities (“help make sure our patients are up to date on routine screenings”). As a result, providers work alone. They rush through 15-minute visits, squeeze in preventive care and chronic disease management, and by default, defer more and more issues to specialists, hospitals, and emergency rooms. In short, the primary care we learn in medical school is far from the transformed primary care we need.
 
The result is a patient experience that is not good. People yearn for the nostalgic image of the community family doc, but today’s guidelines, technologies, and aging population leave no chance for one doctor to provide all the care recommended to an average patient panel. The public, now expecting long waits and rushed visits in primary care, turns to specialists for their medical relationships or to the comforting voices of Dr. Oz and Dr. Phil for their medical advice. Adding to all of this, the environments in which patients receive care are not healing places. Clinics and hospitals often feel cold and foreign, more doctor-centric than community-centric.
 
Despite my medical education, I held on to the glimmering hope that there has to be another way. Primary care is the foundation of every high-performing health care system, and we know that in order to fix our system, primary care needs to be transformed.
 
I felt that the traditional route – medical school, residency, and practice – would only expose me to traditional thinking. So I took a year off from medical school and traveled to San Francisco to work as a fellow with the Center for Excellence in Primary Care. Through incredible experiences working there, I was connected with the Southcentral Foundation. And everything changed.
 
The Southcentral Foundation, a health system in Anchorage, Alaska, serves the Alaska Native population. For decades, they’ve been developing what they call the “Nuka System of Care.” Nuka is an Alaskan Native word for “Strong, living things,” which is what the Nuka system has become. Created, managed and owned by the Alaskan Native population, its vision is a native community that enjoys physical, mental, emotional and spiritual wellness.
 
So what’s different about the Nuka System of Care?
 
First of all, patients aren’t patients. They’re “customer-owners” because they actually do own their health care system. They are all shareholders. They elect an Alaskan Native board of directors, and as a result, they have a unique ability to make sure their needs are met.
 
As a result, they’ve also gone a long way toward solving the access problem. Southcentral has mandated same-day access for its patients, and, as a result, has noted a 40 percent decline in its patients’ use of urgent and emergency services. In traditional practices, this increased access might come at the cost of continuity, and result in fractured patient-provider relationships, but the Nuka system has addressed that as well. Here, primary care teams, including the primary provider, nurse case manager, medical assistant, and clerk, care for the same panel of individuals day after day as a unit. In an effort to encourage both access and continuity, providers are only hired on a full-time basis, ensuring that they will always be available for their patients. As a result of these measures, building long-term relationships is a central component of the Nuka system. Finally, Southcentral’s buildings actually feel like places of healing (see photos 1, 2, and 3.).
 
How do they make this work?
 
First, there is a culture of improvement at Southcentral Foundation that I still have not wrapped my head around.  Full-time (full-time!) professionals serve as “improvement specialists,” and every clinical manager is paired with a non-clinical manager. Improvement is in the hands of people who aren’t tied to medical tradition, so when someone asks, “Why can’t you do this differently,” the answer “Because that’s the way we’ve always done it” doesn’t fly. In the Nuka system, customer service trumps medical resistance. When Southcentral Foundation decided to offer same-day access to primary care, a number of doctors left the organization, but the change was made anyway. And it was successful.
 
Second, customer-owner status means patients hold a stake in the health system’s performance and have real power to institute the change they feel necessary.
 
And Southcentral’s own data suggests this system works. Despite an increasing patient base, the foundation recently reported the Nuka system has achieved a 50 percent decrease in specialist visits, a 40 percent decline in urgent and emergency services use, a 30 percent decrease in days in hospital, a 20 percent decrease in use of in-person primary care services due to use of phone and email, and 92 percent employee and customer satisfaction rates.
 
Now back in the Lower 48, I have a new outlook with knowledge that there is a better way.
 
So what do we do from here? Here are two things we could do today to start moving us in the right direction. First, students and trainees must learn the following lesson well: primary care transformation is possible. From Clinica Family Health Services in Denver to Care Oregon in Multnomah County and even my own residency clinic, the General Medical Clinic at San Francisco General Hospital, case studies of primary care transformation are occurring in a wide-range of settings, with and without payment reform. Second, future primary care physicians should not settle for work in any organization that is not dedicated to transformation. These practices exist. You just have to find them.
 
For now, at the least, I feel like Jon Landau after seeing Bruce Springsteen for the first time. There is a primary care model I can write of without reservations of any kind. I saw primary care future and its name is Nuka system of care.
 
David Margolius, M.D., is a resident at UCSF in the San Francisco General Hospital Primary Care Track. Between his third and fourth years at Brown Medical School, he spent a year working with community health center staff and physicians in San Francisco to improve their delivery of primary care. David is working with PCP as a member of the national Primary Care Innovation Collaborative team.
 
Related links
 
Posted by Sonya Collins on Mar 5, 2013 10:47 AM America/New_York
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