The buzzwords of health reform can sound abstract and confusing. Yet ideas like patient-centered medical homes, integrated care teams and chronic disease management are already reality in what some might consider an unlikely setting for a health-care innovator - Southcentral Foundation, a nonprofit health provider owned by, led by, and serving Alaska Natives.
About a decade ago, Southcentral’s patients made it clear they were unhappy with the care they received. That led to a sweeping patient-driven overhaul of how care is delivered – and defined.
Southcentral views physical, mental, social and spiritual wellness as interconnected. Primary-care teams work closely with mental or behavioral health services, and they incorporate traditional native healers when appropriate. Patients – called customers at Southcentral -- can get same-day appointments if needed, or can communicate with their health teams by e-mail, phone or fax.
By performance and quality measures, including the Healthcare Effectiveness Data and Information Set or HEDIS, Southcentral is outperforming many better known health plans elsewhere in Alaska and in the rest of the U.S. The organization serves 50,000 in the Anchorage area and about 140,000 throughout the state. Only half the patients are insured, through Medicare, Medicaid and private plans; the foundation also receives Indian Health Service funds.
The approach is working on a human level as well, according to Dr. Douglas Eby, a family physician and medical director of Southcentral Foundation, who recently attended an Institute for Healthcare Improvement conference. Here are edited excerpts of an interview with him:
Q: Chronic disease accounts for about 70 percent of health spending in the U.S. Do you have a similar disease burden?
Anchorage Native Primary Care Center (Photo copyright Southcentral Foundation)
A: Ours is higher. The disease burden and co-morbidity [having more than one chronic disease] in our population is two to three times more complex. For every risk factor, it’s two to 10 times as much as the rest of the population. Tobacco use is 40 percent, although it’s dropping. Unemployment is 35 percent. Migration from rural to urban settings plays a role. Diabetes. Obesity rates are double. There are lots of historical and socioeconomic challenges; our starting point is more challenging. But we also have a sense of family and community. A sense of respect for elders. Village identity.
Q: So how does Southcentral take care of a person with a chronic disease, say an elderly person with diabetes and other chronic diseases?
A: Let’s say we have an 81-year-old widower, living alone. We'll call him "Frank." He’s got congestive heart failure, COPD [chronic obstructive pulmonary disease] and diabetes. He calls 911 frequently, and he’s had seven hospital admissions in a year. For us, your primary medical diagnosis is your social situation. So we would address Frank’s medical diagnoses. But we would treat his social isolation. His dependence. His depression. If we can connect to what gets him up in the morning, that’s the primary clinical goal. And that lets us get at the CHF, COPD, diabetes.
Like all our patients, Frank has an integrated care team. He’s on a first-name basis with them, and they know his name. He has guaranteed same-day access to anyone on his care team in person or by phone or e-mail. His choice. He’ll have case management and follow up. They would probably get him elder visitors, and get him into day programs, so he can play bingo with other elders. They’d arrange food, meals on wheels, etc. They would help him with self-care. Gradually, over time, he’ll understand the medications, the physical issues. If necessary, he could see traditional healers. So Frank, instead of having 14 doctors and many medications, has a coordinated primary care, an integrated care team that knows him.
Q: How do you know what you are doing is working?
Dr. Douglas Eby, a family physician and medical director of Southcentral Foundation (Photo: Institute for Healthcare Improvement)
A: We can measure it. We can measure on a population level 10 years of changes. Hospital days are down 40 percent. ER and urgent care (are) down more than 40 percent. Specialty care (is) down 60 percent. Primary care visits, down 20 percent.
In 75 percent of the HEDIS measures, we’re at the 75th percentile or better. Many, we’re at 95. And that’s in a hard to reach population. We’ve had a massive reduction of total costs. Our health outcomes are better. So is the happiness – both the patients and staff, satisfaction is 90 to 93 percent. Our staff turnover is one-fourth of the level it was five years earlier.
Q: Can you define an integrated-care team, which is how you deliver primary care?
A: An integrated-care team consists of a primary-care provider – a physician, or a physician’s assistant or nurse practitioner. It has medical assistants, nurses, full-time case managers who do care coordination and follow up. Visits are precious commodities so we do everything when a patient is in our presence. We call it “Maxpacking.” We save you – and us – a visit, but every visit you have is an intense visit, we cover the waterfront. The medical assistant goes over what the patient needs and prepares for it. We started out having a disease focus – we had a diabetes team for instance. But we moved to integrated primary-care teams. If Frank had to see several different disease teams, it would confuse him.
Q: Good primary care can’t solve all health problems. People sometimes still need specialists. They still need the hospital. What happens then?
Alaska Native performers at the 12th Annual Gathering in 2009. (Photo: Northern Exposures Photography)
A: We have specialists, but the specialist comes to them (the patient in the primary-care setting) when possible. Or they can do a real-time consult with the primary-care team. We co-own, with the Alaska Native Tribal Health Consortium, a 150-bed hospital. When a patient is in the hospital, the primary-care provider will be in touch with the hospitalists, the cardiologists will be in touch. They can say, here’s Frank’s preferences. We have our records. We know him. We have the family dynamics. And we take charge of the discharge. We want it to be more pull than push. Frank comes home. He gets a phone call or preferably a visit at home in 24 to 72 hours. We frontload the home visits. It helps prevent readmission.
Q: Anything else you want to add about Southcentral’s philosophy? About what makes it different?
A: We are evidence-based. We believe in that. But primary care isn’t manufacturing, it’s not linear. It’s about doctors and patients and how well they connect. It’s about messy human relationships. And it’s about partnering.
Reporter Joanne Kenen conducted the interview for KHN.