Southcentral Foundation’s Nuka System of Care has worked with the Native Community in Alaska to implement integrated care teams (ICT). These are co-located, multi-disciplinary teams with a redesigned workflow aimed to do the following:
• Increase access and convenience for customer-owners (SCF’s term for patients)
• Ensure continuity of care
• Improve health care outcomes
• Build trusting, accountable relationship between customer-owner and health care providers
• Build relationships within ICT
Before ICT
• 3,500-4,000 physical visits per year per FTE
• Process rate limited through physical visits
• Nearly 50% of encounters had some behavioral health component
Work that could be handled differently:
• 20% were for Rx refill of controlled diseases
• 20% were for ongoing monitoring of chronic diseases
• 20% needed known preventive medical interventions
• 10% came requesting outside referrals
AND
• 50% total business volume already had known pathways or protocols
Value-added visits:
• 30% of total number of visits were new customers without a diagnosis or plan to date
After ICT
• 36 percent decrease in ER visits between January 2000 and 2015
• 36 percent decrease in the rate of hospital admissions from 2000 to 2015
Integrated Care Team Members
• Primary care provider
• RN case manager
• Certified medical assistant
• Case management support
• Coverage nurse practitioner / physician’s assistant
• Dietician
• Behavioral health consultant
• Integrated pharmacist
• Integrated midwife
• Manager
SCF has exceeded the 90th percentile in Healthcare Effectiveness Data Information Set (HEDIS) measures in:
• Diabetes care annual testing
• Diabetes HbA1c control
• Cardiovascular disease control <100
• Board certification
• HPV vaccine for female adolescent
Do you need to integrate primary care into your organization? Check out our Integrated Primary Care Team Training here.
Integrated Care at Southcentral Foundation
