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Nuka System of Care Builds Trust by Treating Patients as 'Customer-Owners'

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A health care system called Nuka—an Alaska Native word used for strong, giant structures and living things—is transforming health care and the way medical professionals communicate with patients.

Created by Alaska Native people and delivered at the Southcentral Foundation (SCF) since 1998, the Nuka System of Care (Nuka) is a "whole health care system" that helps people achieve physical, mental, emotional and spiritual wellness.

The system's results—measured from Nuka's start to today—speak for its strength: 50 percent decrease in visits to specialists, 40 percent decline in urgent care and emergency visits, 30 percent drop in hospital days and admissions, 20 percent decline in primary care visits, and 92 percent employee and customer satisfaction rates.

As the keynote speaker at the the Association of American Indian Physician Annual Meeting, July 31 to August 5, in Anchorage, Alaska, Katherine Gottlieb, president and chief executive officer of the SCF, shared what makes Nuka as “an award winning Native health care delivery model.”

Among the 65 programs and services offered under Nuka are: medical care, dentistry, optometry, psychiatry, physical therapy, substance abuse treatment, transitional living, prenatal support, adolescent and women residential, elder programs and health education. The SCF also operates the 150-bed hospital of the Alaska Native Medical Center.

“The first step in the redesign process was for Alaska Native leadership to define what our business was really about. It is about human beings,” said Gottlieb, who co-wrote the article Transforming Your Practice: What Matters Most for the American Academy of Family Physicians.

SCF now refers to its patients as “customer-owners,” said Gottlieb, because not only do they play a big stake in managing their own health, but Alaska Natives are also the owners of the health care business.

“Prior to our redesign, the SCF medical system suffered from one of the key problems in health care today. The system misunderstood the core product as being tests, diagnoses, pills and procedures,” she said.

“When individuals sought health care services, providers would take their signs and symptoms, perform a physical examination, and produce a different diagnosis. Then, providers would do what health care does really well: order a bunch of tests,” she said.

With the Nuka system, rather than the provider trying to decide what’s best, the customer-owner makes the decision with the doctor and clinical team providing expertise. “For example, Alaska Native people are inclusive when addressing illness and health, so primary care is delivered with integrated care teams and fully incorporate tribal doctors or traditional healers as well as chiropractors, massage therapists and acupuncturists,” she said.

Building relationships in the context of the Nuka system means removing all barriers of space, attitude, language and time, Gottlieb said.

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To address time, the primary care system has been offering same-day access with 70 percent to 80 percent of appointment slots open on any given day.

“The expectation that everything needs to go through a doctor, who then disburses the work to everyone else, is gone,” she said, explaining that there is a team working on the customer’s medical case.

“If a customer-owner needs or wants the advice of a specialist outside the primary care team, we try to take care of that on the same day. Ideally, specialist access should take only a minute,” she said.

Gottlieb said the key elements of the success of Nuka are found in organizational strategies and processes; medical, behavioral, dental and traditional practices; and a supporting infrastructure.

“Many health care system models in the U.S. are antiquated. They are really not involved in the care,” said Dr. Donna Galbreath, practicing physician at SCF. “We actually involve the patients in the care.”

“The concept of a ‘patient’ is passive,” said Galbreath. “We think of the person in front of us in a different light,” she said, adding that there is a team that treats each customer-owner. There is communication, and over time it builds to a relationship of trust.

“The Nuka System of Care was designed by Alaska Native people for Alaska Native people, but our journey is relevant to anyone wanting to affect better health in their communities.” Gottlieb said.

About SCF

SCF was established in 1982 as a nonprofit health care organization under the tribal authority of the Anchorage-based Alaska Native corporation Cook Inlet Region, Inc. In 1998, SCF negotiated with the Indian Health Service to obtain ownership and management of programs located in the Anchorage Native Primary Care Center. The following year, SCF signed an agreement to jointly own and manage all medical programs on the Alaska Native Health Campus with the Alaska Native Tribal Health Consortium. With the ownership, Alaska became the first state in the nation to have all of its health facilities for Native American people managed by Native organizations.

SCF was the 2011 recipient of the Malcolm Baldrige National Quality Award, the nation’s highest Presidential honor for innovation and excellence. The NCF counts U.S. Representative Don Young among its many supporters. Young has called Nuka a “great model for health care reform.”

“Over the past decade, we have received an increasing number of requests from organizations around the world to visit us and learn more about our continuing journey with the Nuka System of Care,” Gottlieb said. As a result, SCF started an annual conference in 2011 about implementing Nuka and its benefits. The second annual Nuka System of Care conference was held June 18-22 this year and attracted more than 150 attendees from the U.S., Canada and Scotland.