Southcentral’s Nuka System of Care – leading example of First Nations health care

Join the National Rural Health Commissioner, Adjunct Professor Ruth Stewart to see how an Alaskan healthcare foundation has become one of the world’s leading examples of First Nations healthcare design. A recording of this exciting webinar is coming soon.

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In the Nuka System, strong relationships between primary care teams and patients help to:

  • manage chronic diseases
  • control health care costs
  • improve the overall health of the community.

The Nuka System of Care recognises that individuals are ultimately in control of their own health care decisions. It engages patients (known as customer-owners) in their own care and supports long-term behavioural change by understanding each patient’s:

  • unique story
  • values
  • influences.

Click on the below links to see some of their programs in action:

Webinar recording and transcript

1:33:50

Ruth Stewart:

Welcome! It's fantastic to have so many people joining us to hear about what has been happening at South Central Foundation for the last nearly 25 years and the impact that this has had. It's very exciting that they've agreed to do a webinar with us all the way across the other side of the world. And it's a very proud moment for us to be able to share this really good news first Nations story, and so I'm looking forward to hearing more. Every time I listen to stories from the Southcentral Foundation, I learn more. And that's a wonderful thing, isn't it?

So, we've got some great speakers today and this is the end of their day. I thank them for giving some time at the end of the day. We're all fresh, and having our first cups of coffee, you might be having another one just to try and stay awake and rev up the energy levels.

Anyway, here we go. The chat has begun. This is going to be a great, great webinar.

Let's start. So welcome to the Office of the National Rural Health Commissioner's and Southcentral Foundation's webinar on the Nuka system of care. Thank you for joining us, and it's wonderful to see such a great turnout from right across the country and from different organisations and different professions.

Firstly, I'd like to acknowledge the Traditional Custodians of the land from which I'm meeting you from today the Mandandanji people and the Traditional Custodians of the land from where you are all dialling in, I pay my respects to the elders of these lands and waterways, past and present.

I'd also like to acknowledge emerging leaders within all our communities. I extend my respect to all aboriginal and Torres Strait Islander people joining us today.

My name's Ruth Stewart, and I'm the Australian National Rural Health Commissioner. Hearing about South Central Foundation, and then having the wonderful opportunity to visit anchorage Alaska, earlier this year, to see their work firsthand encouraged me to share their work widely.

I have the great pleasure of co-hosting this webinar with South Central Foundation, who developed a truly successful, culturally safe person, centred model of care that is achieving great health outcomes.

Despite familiarity with all the evidence of how to improve health outcomes in first nations, families, and in rural and remote communities, we in Australia still struggle to meet targets to close the gap in health outcomes. We fail in our knowledge translation.

I hope that this webinar will help us all to understand how change and better outcomes can be achieved when we shift into new mindsets and amplify the voice for whom we care. So please listen carefully to the stories about the development and the impact of the Nuka system of care and the role that organisation values and mission can play in every task and interaction in our daily work.

So, I’ll start by introducing your presenters. Let's now hear from Dr. Doug Ebe, Executive Price, Vice President of specialty services at Southcentral Foundation, Melissa Merrick. Executive Vice President of Primary Care Services and Chelsea Ryan, Nursing Director, thank you. And I'll now hand over to them.

Douglas Eby:

Well, Hello, everyone! As was mentioned, my name's Doug, and I'm a physician executive, and I've had the incredible privilege of working here for over 30 years and in executive leadership for about 30 of those years. Working in support of what Alaskan native people have said they want and have led and organised and governed and directed the creation of this whole different way of doing healthcare. We still employ a lot of the same types of people as usual, healthcare. But it's in a pretty different framework, with a pretty different philosophy, and the way we use words and our understanding of the job we're in, and what we're trying to achieve is pretty dramatically different from the usual healthcare approach.

So, our name of our corporation is Southcentral Foundation. And it's a bit of a misnomer. So we're not really a foundation in the usual way. The word is used when we were created a long time ago. Over 40 years ago, someone thought it would help bring in money turns out that's not really true.

But it remained our name. And we're really just a non-profit health corporation. We employ just under 3,000 staff and we provide services to tens of thousands of people and depending how you define it, a couple of 100,000 people. And, as I said, what we're doing is rethinking completely what healthcare's purpose is, and then how you organise structure, what your conceptual framework is what your philosophy is, and even the words we use in supporting people on their own health journey. We're not here to care for. We're not here to treat. We’re not here to do anything to anyone. We're here to understand where people are on their journey, and then to meet them where they are, when, where, and how it works for them and support them in achieving their goals and aspirations, and applying the best that modern medicine has to give us in support of that effort.

So, a lot of people have nice stories. And, in fact, all around the world, there is a lot of proven approaches that work to make a difference in healthcare outcomes. But just so you know that we are worth paying attention to, here is some of what we have achieved on the way. Lower use of hospital and acute care services. Way, more use of ongoing chronic condition management type services and a lot of happy people. So, a lot happier people on the receiving side of our services, but also on the sending side of our services, so customer, owner, satisfaction, employee, satisfaction, and so forth.

Perhaps, most importantly, though, is starting 25 years ago, our governance said they wanted to improve health outcomes. And so, being super brave we went in front of them and said, we're going to try to achieve the fiftieth percentile. And they said, So, you wanna be average? And we said, well, yes, because we're in the bottom fifth percentile for pretty much every health outcome you can measure. And so, getting up there with everybody else, and being average would be an incredible achievement, something that's actually never been done in a challenging environment in history. And they said, well, we don't want to be average, we want to be above average. So, from the very beginning our goal has been the 70 fifth percentile performance and that is the main database in the United States for chronic condition management, and all things prevention and wellness and medical treatment. So, it's a big database that you can benchmark your performance against everyone, including the best in class.

And so, we've now achieved this. With almost no exceptions. We have dozens and dozens of health outcomes. The usual health outcomes that people measure we're now at, or better than the 70 fifth percentile and almost all of them we have just a few left to go to get there. And this is from starting for the most part in the lower fifth percentile. So way better health outcomes at whole population scale

with happier people, both on the sending and receiving side of services. And we do all of this at somewhere around 2 thirds of the per capita to spend average in the US. So less money, better outcomes, happier people and sustaining this now for right around 25 years, and part of what we've achieved also is guaranteed same day access to the people who know you, and who you trust all day, every day, with almost no exception for the last 25 years.

So that's the why you should pay attention in terms of we have achieved something. We don't just have a cute, interesting story to tell. And, in fact, this is one of the things we're most proud of, because lots of people have done impressive things, but very few can say they've done it at entire whole population, tens of thousands of people sustained over 2 and a half decades.

So with that, let's figure out, what did we do. Over to you Chelsea.

Chelsea Ryan:

Hi, everybody! It's such a pleasure to be here with you. Just last night I was letting my 5-year-old, and my husband know about this presentation, and just reflecting on the ability that we have to connect across oceans and to share story. As Ruth said, that was a really beautiful introduction. And I also will share that every time I have the opportunity to hear stories from our leaders like Doug or Melissa. I learn a lot. So I'm really grateful that I'm able to be here with you all.

I am originally from a really small village out in the middle of Alaska. The village size, when I grew up, was about 500 people, and so my mom's whole family was there, my aunts and uncles. I went to school with my cousins and people there was just multi generational relationships. My grandparents came to our house every day.

and I am Alaska, native from my mom's side of the family, and I'm European descent that's mixed from my Dad. He's from the East coast and having grown up in Alaska, not just Alaska, but rural Alaska that's really shaped who I am, and is a big part of me and my identity, and for me something that was really important. As I went on to higher education, was just being able to do something that gave me a platform and ability to work for and with my people with Alaska native people and I'm really grateful that I've had the opportunity to do that at Southcentral Foundation. I've been with the organization for 10 years and in my current role for less than a year. So, it's still very new and fresh and exciting and about 6 years that I've been here. I was an Case manager, and you guys are gonna hear a lot about that later on throughout this presentation but that really being a part of a team that delivers services and connect customer owners with resources is really gratifying and has been really instrumental for me of having that foundation of who we are and what we do here. And where I wanna start is with this slide that just simply says Alaska, native people chose to assume responsibility. And this is what sets the stage for our story.

The United States Government has a treaty obligation and a government to government relationship to provide healthcare services for Alaska, native and American Indian people. And that's what had been happening in Alaska through the Indian Health Service and what was found over time. And it took the US. Government, I think, until the late seventies to formally acknowledge this. They would say our people knew this a lot longer, but that, having a government run owned, operated driven system was not serving the people who was not serving Alaska, native and American Indian people and when the opportunity presented itself for Alaska native people to exercise self-determination, to exercise control over our own future. They took that opportunity, and what's important to point out here is that just, I think back on how challenging that must have been.

In Alaska, native people are incredibly diverse. The lands that they occupy, the subsistence foods that they've gathered and has sustained them over centuries, their relationships. Traditionally, some of our tribes even ward with one another, we traded, we ward, and so the fact that we were able to get over 200 Federally recognized tribes. On the same page to say that collectively this matters to us and we don't have a robust experience or skill set in managing large-scale health operations. But we do know ourselves. We know our people, we know our elders, and the young people are ours, and we want to be the ones shaping and driving what that healthcare delivery looks like. And for me, that's a huge reason that I'm here is to have that opportunity to be a part of the healthcare delivery system where I receive services, where my 5 year old does, where my parents and my siblings and their kids do, and my community and it all really boils down to this choice that Alaska native people made decades ago, and had that vision for and ourselves shaping what this looks like.

We can go to the next slide, Erica and so in sharing that we're just giving you a simple visual depiction here. The top is what our healthcare building looked like. This was where Alaska native people received healthcare in anchorage. You'll often hear it referred to as the old hospital, or ANS which stands for Alaska native services and even somebody like myself, where I didn't grow up receiving care at ANS, It's still a part of our story. It's a part of my story I've grown up hearing about ANS and yes, a piece of history that is still very alive for a lot of our customer owners, who remember what it was like to go there and wait all day for a simple primary care appointment. Their kiddo has a sore throat, and people would talk about packing up lunches of calling out from work, because they knew that they would be there all day long, and that there was no way that their kid was gonna make it to school. There was no way that they were gonna make it to work.

I think some of the plus sides is they would run into a lot of friends and family while they were there. But the downside was that it was really disruptive. In the ability to access care when you need it, how you want it? And without going through an emergency department or without seeing somebody different each time and having to tell your story over and over again. And how this, how I've seen this, and I've felt this in my life that I can share is about 5 and a half, 6 years ago I was at our inpatient hospital, which you can see. It's the furthest building back in the picture below Alaska Native Medical Center, and I had received all of my prenatal care at Southcentral Foundation, and it was time where it was very clear that my son was entering the world, and so I was at the hospital and my mom arrived. I distinctly remember this moment because I was so frustrated by but she said to me, remind me why you decided to come here again, and I just had this, you know, frustration. I'm in pain, and I'm tired, and this is a very big moment for me, my first baby, and I was thinking, you know, this is not the right time. This is the eleventh hour. If you had concerns, you should have brought them to me a long time ago. But as I was able to reflect on that, you know, I realized that my mother was Alaska native, and has given birth to 5 children, has not delivered a single one of us at the old hospital or the new hospital, and part of that was that the way that care was provided, the outcomes, the overall experience was not one that people were beating down the doors to have honestly, a lot of our services were the choice of last resort. If you had nowhere else to go or no other options. People would seek out care, but otherwise, if you had the ability to go somewhere else, people did. And so for me, as my mom was there with me, I was able later on to have compassion for her, that that was coming out of concern, that she had as my mom for me and for her grandchild of is this, okay? Are you in a safe place? Are people gonna take care of you? Whereas for me, that hadn't been the experience, I'd received just high quality, outstanding care both in our outpatient and inpatient settings.

But it's important for us that, regardless of how far we are in our journey that we remember where we came from because our customers remember it. It's a part of their story. It's a part of the stories that we passed down and it really sets the stage for the transformation we've undergone and continued growth in the organization. So the bottom picture there, that's the Alaska Native health campus today, and I'm sure Doug and Melissa would agree. Is, we've seen this campus grow up over time. I think I've just been on the campus a little over 10 years, and we have Doug and Melissa who’ve been here much longer.

and there's so many new buildings, and it's not just buildings that services and staff who we bring on to help provide care for Alaskan native people.

So, we're gonna talk about our vision and our mission. And so the vision of Southcentral Foundation is the native community that enjoys physical, mental, emotional, and spiritual wellness, and our mission is that we will work together with the native community to achieve wellness through health and related services.

And this is a mission in a vision that's very powerful. It's very palpable in our organization. And to me, what I love about it is that it's holistic, and it's something that I want for myself and my family and my community is that whole person wellness and for Alaska native people. We really are community oriented. We are family oriented.

I once heard an elder talk about you know that sometimes there's this feeling that I things aren't okay. Because if things aren't okay in your family or they're not okay in your community, we feel that because we're a very communal people. And so this vision and the fact that it's not based on Chelsea Ryan will enjoy physical, mental, emotional, and spiritual wellness but is that all Alaskan native people that our community is going to be well. To me that just speaks volumes.

And it's very representative of who we are as Alaska native people. This is something that I would say that are close to 3,000 employees, that they know this, that they hear this that it's a part of so many different platforms that we have when we are with our workforce. But it's also a part of our day to day conversation, and it's a part of our decision making, and in the leadership meetings that we might have, and with ideas and tension and challenges we go back to. How does this advance the mission and vision of what Alaskan native people are expecting our organisation to do, and what we've said is important for us to do that you, the customer owner. You guys have already probably heard that term already in our short few minutes we've been with you. It's a term that you're gonna hear a lot more of throughout this presentation, and customer owner is a term that we use to refer to what many other healthcare organisations would call a patient and there was a very intentional decision early on, long before I've been here that we don't serve patients. We serve customer owners, and the reason and part of the reason that is that Alaska native people own their healthcare and we're also serving Alaska native people as customers who are coming into our system into their system to receive services, and more than that, customer owner has an implication in it that's very active. It's not a passive term, like a patient of somebody who comes in and you do something to them or for them like Doug was talking about. A customer owner is somebody who is actively engaged. We're not going to be operating in a paternalistic framework of okay, I'm a nurse, or I'm a doctor and I went to a lot of school, and I'm very smart. So I'm gonna tell you what you need to do right again. It really is about that relationship that respect, and meeting people where they are at to advance their wellness wherever they're at on that journey, and customer owner is the term that we use.

And to me it's it's really important and it's something I share with my 5 year old when we come in for appointments. For his child checks, you know, as you know, you're the customer. This is your provider. Do you have questions, and really trying to foster that within him that this is his experience. Coming into our clinic. And yes, there's certain questions that are going to be asked. There's certain vaccines that we want to deliver on a certain timeline but you're the one who's, you know, kind of mapping that course as a customer owner, regardless of how young you are or where you're at on that journey.

Douglas Eby:

So the usual modern medical model is very institution centric and very provider centric. So it's all set up around my convenience as a physician, and my efficiency, and all the words and models and so forth, are based on me, having the expertise and the person on the receiving side, waiting to be told what to do. So the usual medical model is, you come and see me, I listen for a couple of minutes, and then I give you a diagnosis, and then I tell you what to do. And then, if you don't do it, I call you non-compliant in my paternalistic judgmental, arrogant way and then judge you and then tell you again, here's what you should do, and we know that doesn't work all around the world. There are better models that have been created.

And it's changing that power structure so that we understand that they do own their own journey, and that they have choices like any customer, and our responsibilities to provide them with options to choose between and then support them on that journey. But it's not all just about relationship. That's the key, that's the thing our systems built on. And Melissa and Chelsea are gonna describe to you the mechanics of how we're organized and set up.

But we're also pretty darn smart about the science, the data, the best practices, nationally and internationally. So just a couple of slides on fundamental understanding of work and work flow because it's not just the magic of relationship and customer ownership and respect, although that is the main thing. It's also understanding really well the science, the methodology, applying quality, improvement structures and best practices, and so forth to the practice of healthcare.

So it turns out that you can kind of predict what people come for. There's buckets of what people come for, and part of the job, then, is to figure out how to best meet those predictable things people come for. This slide tells you there's, you know, several different major buckets of things people come for in your average primary care, setting in the usual system, you do this rate limiting step so people come in. They see different staff members, and then everything goes through the physician or the provider before then something can happen.

So just in terms of industrial design, or pretty much any workflow design in any business. It's good to avoid rate limiting steps, and the provider on this slide is a rate limiting step. Things happen. Everything goes through one squeeze point before it can then move forward. This is bad design, no matter what business you're in. Next slide.

So what we wanted to do was parallel work design. So we figured out, these are the things people come in for, and these are all the people we have to help provide the service. And how do we get the right problem to the right person immediately so that we don't waste all this time on provider-centric institution centric grade limiting flow processing. And this is a really really big deal. Now, you don't want such a big team that you can't have personal relationships. So again, Chelsea and Melissa are gonna talk you through our actual structures. But it's a limited number of people who are available at any time all day long. Same day access for a multitude of issues. Whatever your issues or challenges are, in whatever way you want to connect phone, email, text, video or in person doesn't matter. And then we do this parallel processing of work, where people sit together in a very intentional way and meet all the needs all the time but in a team based, not parallel processing approach next line.

This is my favourite slide, because this is the fundamental understanding that modern medicine does not seem to want to understand that we believe you must understand. So in a high acuity environment. So if I get hit by a car on a street, I'm laying there unconscious and the emergency medical people scoop me up and do things to me. They take me to the emergency room, do things to me. They take me to the operating room, do things to me. I'm passive, they're active. That's on the right hand side here. High acuity. The system has control, and I have no control. But that's a minority of what happens in health care. The majority is what's on the left side here, where people live with chronic conditions over time. So they live with diabetes, blood pressure, depression, anxiety, all kinds of different things that happen in people's lives. And the reality is they're in control. They decide whether to even come for advice. They decide what advice they're gonna follow. They decide whether to take their pills or not take their pills. They decide whether to exercise, what they eat, what their sleep habits are. They decide whether they lash out violently when they get frustrated or not, and problem solve in a different way, something like 90% of the variables that determine their health outcomes and how well they live with their health challenges are under their control, and they are making the decisions all day, every day that drive their health outcomes, and modern medicine wants to pretend this isn't true, that we have all the answers. We tell you what to do, and then call you noncompliant when you don't do them, it doesn't work. We know all around the world. It doesn't work. And yet it is how the system is set up over and over and over.

So we have to if we're going to be successful, we have to accept the fact that they are in control and we are here to advise, coach, mentor, provide access to resources and things like medications and other treatments and surgical things, but on terms that work for them to achieve their goals, when, where, and how it works for them. So if you don't learn anything else from this whole talk, believe this slide with this diagram, and rethink the entire way. You distribute your workers, your work and your workflows, and so forth.

Melissa Merrick:

Okay, so this is my turn. So just want to start with a little bit of framing for kind of what drives me here at Southcentral and the work that I've had the pleasure of supporting. So thank you, Doug and Chelsea, for the kick off. So, I Melissa, I've been with South Central for 17 years, and I have a background in behavioural health. I started at South Central as one of our first behavioural health consultants. And so, we'll learn more about that role. But that role was really embedded in primary care with the goal of helping support the primary care teams to support what is the family the customer owner want. When I started at Southcentral, this slide, which I'll talk through, looked similar, but a little bit different.

Given that, I've been here 17 years. We were about 7 to 10 years into our same day access journey at Southcentral Foundation. And so, as we've continued to be on this journey, we've realized that we need to bring more and more customer, more and more services to the customer owner in the family rather than have them go elsewhere for services.

So if I follow that this slide starts at the center, with the customer owner and their family at the very center. These concentric circles are really wrapping around the customer or customer owner and the family to help provide a journey of wellness together. Every customer owner in our system is in panel to an integrated care team, and that care team consists of the individuals in the first circle. I guess that would be the lighter blue circle, and that would consist of a primary care provider or a general practitioner. It could be a physician, a nurse practitioner. They also have a RM Case manager, a medical assistant, and then a CMS or often we would think of of that individual, maybe, as helping, support scheduling, and all of those individuals work directly with the customer, owner and the family they have. The individual has a direct access line to every single person on that team and has the ability to connect with that team on a regular basis. We'll talk a little bit more about those roles here in a minute.

The next circle, the dark, the not the darkest blue, but the darker blue circle has support resource resources that are embedded in primary care. So, in the clinics, we have integrated behavioural health consultants, so integrated mental health providers, integrated nutritionists or dieticians, integrated pharmacists, integrated certified nurse, midwives or individuals that support prenatal care and women's health, and then, individuals who do kind of resource or referral. If somebody needs more support to get to a shelter or housing, food and security, the community resource specialist could help with that. So all of these resources come to the customer owner when they are in the clinic, or the customer owner can schedule directly with them in primary care and because they're all sitting side by side, they have the ability to work together the different provider types to talk to each other, to work together, to kind of anticipate what the family the customer owner, might need.

The darkest blue circle on the outside are individuals that are also within the primary care setting but they're not, they have a little bit more specialised training or specialised function. They still come to the customer owner within the primary care setting, but they often might be time limited. So, a lactation consultant that's helping support infant feeding an ability to have a home health provider, post-surgery and an integrated psychiatric team, a paediatric provider. So all of our primary care clinics now have an integrated paediatric provider and part of the goal of these roles is to again bring support to the customer owner rather than having separate clinics that they go to, but also to help up skill or increase the generalist knowledge of all of primary care, so that we have a robust, high, functioning, primary care system.

The outer circle are specialists who we would refer to, on this campus or within our system, so something like cardiology or optometry. But they still interface within the primary care team to help support continuity of care and healthy transitions of care driven by the customer owner. So there's a lot on this slide. We're gonna unpack it a little bit more in the next slides and then come back to it.

So the integrated care teams, there's Chelsea on there in this slide. This is a slide that shows how all the team sit together, so there are no offices. Physicians don't have their own offices. Executives don't have their own offices. Everybody is sitting together as an individual who's worked in this environment. One of the things that I love about it is that I have the ability to hear Chelsea as a nurse on the phone with their customer owner, who I just saw yesterday as an example, and I can. I can hear what they're talking about, and I can add my perspective as a behavioural health provider, or she can just reach over and ask me a quick question about the care that that we're co- providing together.

It's also an environment to really learn from each other and support and just an overall fun environment. But the idea is breaking down those silos and walls and having the teams communicate and work together in spirit of the customer owner rather than my medical training has earned me a private office where I get to sit. We all sit together and work together.

Both Doug and Chelsea did a wonderful job talking about this idea of shared responsibility and customer ownership. Part of our journey is really learning that the customer owner and their family know what's best for them. That doesn't mean they don't need support in education to understand the course of diabetes or a complex condition but they know what treatments are gonna work for them, and what treatments may  be harder for them. So, this idea of shared responsibility is really about breaking down the hierarchy of care. Yes, a provider has medical nursing, behavioural training but we are on this journey together, and let's co-create the plan. Let's co-create what's gonna work for you so shared responsibility. Being a key component, we want, as Chelsea described with her son. We want customers to come in and advocate for themselves. We want them to ask questions. We want them to get curious about a variety of things that are important to them, not just have that visit or those interactions be us as providers, sharing information, it should be dialogue that's back and forth. And that's shared responsibility and action part of what makes us shared responsibility really work is this idea of continuity. So, I always say that content continuity builds trust, it builds respect. It is trauma informed. When customer owners know who they're gonna interact with, and they interact with the same individuals on a regular basis. It helps break down those barriers of care. And we, we are in shared responsibility and relationship. Together. They learn about my family. I learn about their family, and that con continuity is key to everything about our relationship based system.

So empowered customer owners have that core team member that will learn about those roles. And what I love about this core team is that if Chelsea as our end case manager is on vacation, there's already there's already somebody on that team that knows that customer owner. So continuity happens with every member of that integrated care team, not just the primary care provider. And again, that looks like open access to the integrated care team. So same day, scheduling interactions that are phone based, they're virtual based, it is calling. And I just got prescribed this med medication, and now I have questions about it rather than calling a provider's office waiting for a call back from that physician. A customer owner, can call and actually have dialogue with their RM and case manager around what questions they have same day. So continuity looks different in a lot of ways depending upon if if it's all about wrapping around the customer, but how it interacts is different. With each integrated care team. But each integrated care team has the ability to work directly with the customer owner and all of these different kind of mechanisms, phone in person, etc.

Alright. So now we're gonna dive into ratios. What this is showing is that we have again the primary care team, what I like to call kind of those core 4 members, the primary care provider case, manager, scheduler, or case management support, and the medical assistant. One of our journeys over time has been that right sizing the these in these panels, making sure that these team members, the primary care team, have enough time to work and really be in relationships with their customer owners means we need to often add more teams. We need to have right sized panels. And so, we believe a good size panel is about a thousand to 1,200, sometimes up to 1,400 in individuals, customer owners to manage when I started our panel size as an example, we're probably closer to 17, 1,800 per provider. And so, we've really tried to bring those down.

Yeah, and know that not all the work needs to be done by these, this core 4, it could be done by the dietician. It could be done by the BHC, so really utilising the team around you, the integrated resources help support high quality care, but doing it with ratios that are optimized so that we can provide that care.

The other thing that I just wanted to mention very briefly, is that these ratios are something that we have played with over time. And one of the things that we do always allow is that family continuity. So, if Chelsea's family wanted to be all on the same panel with the same care team, that's absolutely something we would allow, and we encourage and support, so that we have family annuity. But if there's choice, so part of that shared responsibility is customers choosing what makes sense for them, and if they have choice and choose to be with different providers, that's also fine, it's really driven by and for the customer owner. Chelsea is going to walk us through the first couple roles of the integrated care teams.

Chelsea Ryan:

Okay, thank you, Melissa.

We can go to the next slide, Erica. So the first role that we're gonna talk about within the primary care team is actually our provider Melissa had mentioned that this could be a physician, but this also could be an advanced practice provider and to me the role of the provider within our system is in terms of the technical day to day responsibility. It's probably the most similar to what you would see external to our system, where our providers are responsible for assessing, diagnosing, setting treatment plans, and prescribing medications. And then, you know, there's also work for them to do here in, you know, following up on those treatment plans and plan of care is what we thought was going to work. Is it actually working? Do we need to change course?

But they also are really instrumental in setting the focus for team on priority work areas. I'm gonna steal Doug's words from the other day we were talking where really, our providers in our system, what needs to be different is that they need to be able to play nice in the sandbox right? And kind of get out of their own way in terms of hierarchy and advanced medical training where they have to be interdependent on a team to really fulfill the work that we're doing, and the accountability that we have to a caseload or a panel of 12 to 1,400 customers, providing high quality, accessible care on a population health level. Is that it's not possible for a provider to do so they need to leverage that relationship with not just their nurse, but their scheduler their behavioural health consultants, etc. So that's one of the real big differences is that and we hire for that we hire for people who are interruptible. We say that right for people who can be in a shared setting, who are teachable who are willing to teach as well right, but no one that we all have something to contribute to each other in a team-based environment. And so the provider is seeing the customers who are coming in in person on a schedule that averages about 12 to 14 customer owners a day, and they're in that room engaging in providing that care, and they're also supporting the team on the work for the customer owners who may not be in person physically. But there's always work that's happening behind the scenes. And so, we'll shift to talking more about the other roles.

So the RN. Case manager. This is a fun one for me to talk about and relive my glory days of being an RN. Case manager and all the triumphs and joys and also challenges. It's a really dynamic role. And when you hear the word case manager, at least in the United States, it could really mean any number of things. It doesn't always mean that it's an RN but the ones who are registered nurses are often very focused on

on specific conditions that are high disease burden, high cost. So people who are working with a specific population, whereas at Southcentral Foundation our case managers are registered nurses, and we're supporting a panel of across the lifespan. It's birth through end of life.

And what I love most about this is that our case management model really mirrors what our healthcare system looks like. It's holistic and so you are supporting customer owners with acute needs, doing telephone triage, helping to direct customers the most appropriate level of service in partnership with the provider.

There's chronic disease management that takes place and we love to be proactive as much as we can and somebody having diabetes isn't a surprise, right? So, by making sure that we're playing our part to help them stay up to date with care, and the time, intervals of doing labs, of making sure there's foot exams happening that there's access to eye exams and seeing a provider at a set interval is really important.

We shouldn't be chasing that, we should be planful about it and the RN. Case manager. That's a lot of the work that they're doing. The favourite thing about being a case manager was the preventative work that we do, and that our teams do. That's largely driven by RN and case managers. We have a really robust data mining system that allows us to pull information, in an efficient way, sophisticated manner, to give our teams real time data on their panel of and how they're doing managing conditions like diabetes, access and connection to colon cancer screening. Alaskan native people have some of the highest rates of colon cancer in the world. That's a really big deal. And so to me, that connection with preventative screenings is just one of the most powerful things that we can do. It's, you know, getting ahead and finding cancers, finding conditions early on offering treatment. And that's what makes a huge difference in the overall health of our customer owners and the work of our end case managers is primarily this is extraneous to the physical visit. So the majority of the work is happening in the electronic health record. It's happening on the phone. Occasionally we get to pop out and visit a customer who might just swing in because Melissa had mentioned that continuity where our customers should not have to jump through hoops to access care.

At the end of the day it's a relationship. So even if somebody doesn't have an appointment, but they stop by our front desk. and they need to speak to somebody, or they have a whole bag of medication that they're confused about somebody from their team is gonna greet them and sometimes that's the RN and case manager, because we're able to go in there quickly and kind of figure out. You know what is the need, and how can we best support the individual. A lot of the work that RN case managers do is providing education and follow up for our customer owners on what labs they had done with. They were in clinic so what the results were, any recommendations from the provider in terms of follow up or referrals to other departments. And this here mentions medication refills, and Doug showed on earlier slide that's a lot of what people are seeking. Their care team for is, how do I get a refill, a medication? And so, this is something that we really train our case managers on being mindful about doing an efficient chart review but doing a thorough one. We don't want people to have to jump through a hoop of coming in to see their provider if they're up to date on care. And so, it's finding out and providing a quick chart review that's documented in the chart that I could send off to Doug that says so. When this person called they are looking for a refill on their Metformin. This is their diagnosis. This was the last time you saw them. This is what their labs were, and this is the plan. And here's a proposal to refill that medication for the next 6 months, and at that time they're going to be due to come back in. And so that's some of the work that the R and case manager does is really this connection point for our customer owners and seeking care and directing that out within the team. And so the next role that we talk about here is our case management support our case management support. They work really closely with the RN and case manager and there's one case management support on every team, and they are responsible for some of those administrative tasks and duties. And so to me every once in a while. I'm sure Melissa and Doug have both heard this but we'll hear our case management support say I'm just a scheduler, or and I think all of us, it stops us in our tracks where it's like you are not just our case management support. They play a critical role in our team. So they're that first point of contact that most of our customer owners have when our customer owners are calling for an appointment for a medication refill for a hey! The provider referred me to physical therapy, and I don't have the phone number, and I haven't heard from them. What do I do so our case management is supported. They build relationships with our customer owners by being that person who is on the phone. They schedule appointments. They you know, help assist with getting orders for durable medical equipment where they need to go getting things scanned into the chart communicating in the chart for me. They made a very key difference in the sense of doing some of the basic preparatory questions of the customer owner who's calling in. You know. How long have their symptoms lasted? Are they having a fever? Have they done anything at home right? And they're either sending a message to the RN. Or we have scheduling guidelines, and there's a list of symptoms and conditions that are an immediate triage. So, they know that, oh, boy, this person has chest pain. I need to get them to Chelsea right away to talk. I'm not sending a message.

And so again, I think this role is very, very important. It's just as important as having a strong provider having a strong RN and case manager. And I've seen this recently with my mom. She was kind of having some trouble you know, getting in touch with her team, but the case management support was the one person for her where she was like, you know, Daniel always answers the phone, and he always calls me back. And that is so important to people and to me that's really important. And so I can't say enough for how important each of these roles are in working together.

Our the last role that I'll talk about here today is about our certified medical assistance. And you can go to the next slide kind of describes what this role is. So our cmas also very, very key role within teams and they do a lot of work that theoretically you know, we could have our ends checking in customer owners. We could have RN ends doing venup puncture and immunizations but when we look at the type of work that we're doing, it has made much more sense to have a certified medical assistance. Somebody there with those technical skills to not only pull our customers back and greet them from the lobby and bring them into the care space, and do an intake and gather vitals and provide immunisations and draw labs

They do this day in and day out, and they do a fantastic job. And in that they're building relationships screenings for substance, misuse and depression. Our cmas are just as active in pulling in somebody else for care to support a customer owner as anybody else on our team and I think that's really unique about our healthcare system is that we're the relationships that we build amongst ourselves need to be free of hierarchy and need to be clear for all of us to work together. And so you don't need to be an RN to pull in a behavioural health consultant. You don't need to be a provider to say, Hey, Melissa, do you or one of your peers have time to talk to this customer after they screen positive for depression, or they've shared that they, you know, are just going through a really tough time right now, right? It could be anybody on that team who helps make that connection for the customer owner and often times that is a Cma and beyond doing those technical hands-on skills.

Our Cmas are also helping to manage that daily schedule of 12 to 14 customer owners. So they're looking the night before... Who's on our schedule tomorrow? Who's due for immunisation? Who's due for an annual screening and XY and Z. And then they're managing the schedule as it takes shape the day of, and that to me, is one of again one of those high points of our teams of this team of 4 where you really need to look at them in conjunction with one another because it is team based. The best work happens when everybody is working parallel to one another, and they kind of know their lane, but sometimes they might swerve into the other as an RN. There’re times when I can tell that my case management support is just bogged down or having a hard time on a telephone call and Melissa showed the picture earlier of how closely we work. We can feel each other when that happens. Right? I can hear that phone call. And I can turn around and say, hey? Transfer it to me. I'm happy to talk to this customer, or you're doing this. I'm gonna get up and do that fax. Where does it make sense to be paying our end to be faxing all day. No, it doesn't. But it doesn't mean that I can't do that to help my team. And so you really have to maintain a strong awareness of the team. You have to maintain strong awareness of how we're doing, how we're doing in metrics. And we have metrics, and I think we talk a little bit about that later. But there's accountability on each of these different positions equally, but in different ways. And so we're gonna shift gears and talk, I think about our behavioural health consultants.

So our behavioural health consultant role, I briefly mentioned when I was talking through the Circle picture, but we integrated our behavioural health consultants into a primary care. Probably almost about 19 years ago. Our goal at the time was a couple of one was, we had incredibly long wait lists to get into what is often known as mental health or outpatient behavioural health. We use the term behavioural health very generically here to encompass mental health concerns, substance, misuse, behaviour, change. So, it's a very broad term that has an umbrella, an umbrella term that has multiple different aspects of care.

We also wanted intentionally to acknowledge that a huge part of somebody's wellness is their emotional wellness, and so bringing a provider into primary care to have intentionality around. Emotional wellness helps support customer owners emotional wellness, but it also lends a helping hand to the primary care providers who are juggling.

We have a variety of different things. So, as we've had this role in primary care for many years now

we have expanded the amount or the ratios, the number of BHC's we have per primary care providers. So today we are probably at about 2 one. Excuse me, one behavioural health consultant per 2.5 providers. So that would be helping one BC, who is available for roughly 3 to 4,000 customer owners, and we actually don't think that that is enough. We think there should be more of that one-to-one ratio.

The Vhc. S. are in primary care and are providing what I like to say population based behavioural health.

Melissa Merrick:

It is available to every customer owner. There is not a long assessment that is needed, or a variety of paperwork that is needed to see the behavioural health consultants here in the United States mental health treatment often is very. It's a long process to get into. There's a lot of challenges. And so we wanted to break down those barriers and bring the resource to customer owners and primary care. And so what that looks like is a variety of different ways in which the BHC interacts with the customer owner and or the primary care team so we can provide consultation and education to providers and case managers. Just really anybody in the care team.

We provide joint visits and care conferencing. Let's talk. Let's all sit down together and really talk about with the customer. What's a good plan of care for them? What makes sense? Certainly there's educational materials and workbooks, but the bulk of our work is really working directly with customer owners, and when I started we had very targeted ways in which we would get in the room meaning that we do routine mood based screenings, substance, miss screenings, and these ways in which primary care providers would pull us into the room and these days we have those. But we actually don't need them as often because customer owners know to ask for a BHC and we give primary care providers a ton of flexibility to say, as an example this customer owner was coming in with chest pains. I did a brief workup for what I thought was maybe a heart condition and all of that looked good and I think they're experiencing some stress and anxiety, and so I would go right into the room and meet with the customer owner. Real time right then and there, provide some education and intervention driven by the customer owner and come up with a plan of care. That plan of care often is seeing me again in primary care, but it could mean over time that I refer to a longer term therapist or a specialist for longer term kinda interventions. But the Hub always comes back to primary care in the primary care, behavioural health doing that, has allowed our customers to have again same day access to behavioural health in primary care for almost 20 years, and most of the all, I would say 80% of the behavioural health that happens within our system happens through primary care. And so, this idea of putting emotional wellness right next to physical wellness, it's all part of who you are and we're not gonna separate it. We're gonna bring it all to the customer owner and teams working together.

There's a just amazing amount of synergy and flexibility that comes with Chelsea and I working together, working with a provider to really talk through with the customer what makes sense for their plan of care and recognizing that stress and things happen in people's lives, and they're just as important to talk about as somebody's blood pressure, their diabetes, their cardiovascular care, etc. One more note is that we do allow customers to call and schedule directly with the PHC so you don't need a referral with the provider, so we often will do scheduled visits where customer calls and says, I, wanna see a BHC. We do those same day what we call drive by visits with customer owners who are in clinic and all of the care team members Chelsea just talked about. We'll give them the flexibility to pull in a BHC so, as a medical assistant is checking in a customer, they can actually say, would you like to talk to Melissa today? And I can go in the room.

Chelsea, as a nurse or the provider doesn't need to approve that. We give everybody the flexibility because continuity with that team they know their customers and they can sense what something's maybe feeling a little bit more stressful. We don't wanna have to put up barriers. And so really, we're responsive to everything. I always say there's not a topic we don't talk about in primary care. We talk about it. Everything under the sun related to emotional wellness and continually kind of pushing on ways to be supportive in this role.

So, as we have a next slide, please, as we have worked through these different layers of resources within primary care. We also are focused on how do we continually provide same day access to behavioural health so as a refresher customer owner at the at the centre  the core team that we just talked through the outer circle or the next circle, and then you get into additional supportive resources, all within primary care and they are very specific roles designed to be in primary care. The longer we've done this, the longer we've been in relationship with customer owners the more work there is. I always say this because it doesn't mean the work wasn't there but when you're in relationship, people share story with you. They talk about what's important to them. And so, as we built up more behavioural health within primary care more supportive resources in primary care, we realised we needed to also build up behavioural health elsewhere in our system. Next slide, please.

So, we have really this idea of behavioural health everywhere, I'm not gonna go through all of these programs. These are very specific programs that are more specialty or traditionally, behavioural health mental health programs like outpatient and inpatient substance use treatment long-term therapy, psychiatry, etc. The idea is that we want there to be behavioural health infused everywhere throughout the system and doing that through primary care, but knowing just like a customer might need to see a cardiologist, they also might need to see an outpatient psychiatrist. They might need to see a long term therapist so, we built behavioural help everywhere throughout our system the hub of it being within primary care.

I'm gonna transition to Doug, who's gonna talk a little bit about our rural services. The one thing I just wanna note is that all of these principles we've talked about so far apply to our rural settings as well. It looks and feels a little different depending upon the community, but the goals are the same, and that customer driven shared responsibility, care driven by and for the customer owner applies in all of our rural settings as well.

Douglas Eby:

So, we're a little bit like Australia, in that we are physically very large. So, in order to make that point, there's the Continental United States, the other 48 States, and then Alaska on top of it in proportional size. So we're very, very large and then the whole blue area at the bottom. The lighter blue area is the rural area that we here in our corporation directly support. It's about 2,000 kilometres end to end, and about a thousand 300 kilometres north to south. It's a very large geographic area, and most of it does not have roads. Most of it is accessible only by small plane or by boat, but primarily by small plane so lots of logistics and challenges in rural service support so we have clinics. Every single village there are, over 200 remote villages and dozens of small towns all across Alaska. Every one of them has a clinic, a physical clinic in it, and every one of those clinics is supported by an array of people that are hired locally and then trained, which we'll get to in just a minute. But every region also has a community health council and this is extremely important to us. These community members are leaders in their community. They can be tribal or non tribal, usually a mix of both, and we meet with them to talk about what we've done, the complaints or suggestions we've heard from them, how we've responded and what works or doesn't work for what we've tried to do.

There's a question in the chat about size. The smallest of these villages is about 550 people, and the largest is about 6 or 700. So it's a range of size of villages, but definitely on the small side next

the clinics themselves are staffed with what's called a community health aid. They're supported by community behavioural health aid and a dental health aid and also a community like a mini social worker, so kind of mini medical person, many a behavioural health person, many social worker person, and they can be supported also by what's called a physician, assistant, or advanced practice provider, like a nurse practitioner. Most of our villages have only health aids, some have nurse practitioners and then we sub. They are physically present so someone always physically present, but the urban centre is not off the hook.

We provide support all day and all night, every day to these people. So every one of them has a primary care team. That's just as Melissa Merrick and Chelsea Ryan described. So those teams have about 90% of their work in the city and about 10% of their work by video and phone supporting remote set of people in a village. It's all one system, same expectation, same philosophy, same guarantee of access. Next,

we have a couple of fancy things like every single village has one of these machines. It's a tele pharmacy setup so these machines are like vending machines like for candy or chips or pop and but they're controlled by the computer, by the pharmacist far away. So in the person here is a community health aid. They see the person if necessary. They talk to the physician in the city. They decide the person needs medications that is entered in the computer, to the pharmacist who sits in the city in anchorage and then they from a thousand miles away or hundreds of miles away, control this machine remotely and it drops the medication and prints the label, and there's a little camera, and the health aid puts the label on the medication, opens it up, shows it to the video camera of the pharmacist closes it back up and then gives it to the person for their medication. So it's pharmacist control pharmacist overseen same quality standard. And then all the inventory is managed by the pharmacist as well, so that nothing expires and goes bad and a lot of our villages have pretty impressive setups like here is an X-ray machine over top of a trauma bed. Not all our clinics have this capacity, but probably about half of them do, and the smaller clinics feed into the bigger clinics. We can do a lot remotely with technology. All these X-rays, for example, are digital so you can take a digital X-ray digital. You can take a photograph of an eardrum you can do lots of things through cameras and testing equipment that then is sent digitally to the city where the experts in the city then read them and then help support the local provider in diagnosis and treatment planning next back to you.

Melissa Merrick:

Okay, so we've given you this journey of our transformation and our care delivery. All of this wouldn't be possible with without corporate infrastructure support. So, this slide touches on something that Chelsea talked a little bit about, which is our data structure. All of our integrated care teams have access to a variety of clinical data reports, action lists. Sometimes they're referred to that helps the team manage chronic common chronic conditions. We also look at as an example operational data related to same day access so we're monitoring on a regular basis, clinical outcomes. We're monitoring access to teams. How often our team, our customers, seeing the team they're in panel to, and how often are they able to get in within our specified timeframe. Those are action lists that everybody can look at. They're public, they're transparent. So, we kind of unblind the data. The clinical data has a little bit more limitations in terms of who can see it. But the idea is that we are monitoring data on a regular basis to make sure that we're meeting our goals and we're using it as a tool to help us deliver high quality care.

We also seek feedback around, what data are we missing and how do we build on and add to that data so that our teams have the ability to do their job and do it well at the corporate level, Chelsea started us by talking about our mission and vision. And so, our mission and vision cascades down to every employee that works here regardless of your role.

We have corporate goals. So, these are 5, 10 year goals, corporate objectives, 3 to 5 years, corporate initiatives that are more on the one to 3 year, and annual plans. And all of these linkages are connected. They're connected to ensuring that we are building services and growing the health of Alaska, native American, Indian families in our in our community.

What I’d like to just really highlight with this slide is that every employee is connected to this. Every employee has the same performance development plan, the same evaluation categories. There are 4 categories that we look at for every employee. But what's in those categories So, for Doug and I as evps what's in the category of customer care and relationships might be different than what's in the category for a Cms a case management support but we all have those same 4 core areas that help ground us in our foundation and our structure. It links to the work of corporate initiatives, corporate objectives, an example reducing cardiovascular disease, trauma prevention, operational sustainability, all of those different objectives and initiatives. We build all of this infrastructure, what's the improvement work that we're doing and the work we're sustaining based on feedback from our communit.

So, we have a ton of ways in which we listen to the community, and our customer owners. Part of the embodying the idea of customer ownership is that our customer owners own this healthcare system. They have a right to contribute, and they should. We want them to contribute to what's the work that we're doing and so we listen to the community on a regular basis. These are some ways in which we do that we have surveys, satisfactions card, annual kind of listening posts or gatherings. If I can just touch on one area, briefly, an area that we've heard over and over again from customer owners is they want more behavioural services. It is an area that we are growing rapidly in our company to make sure that we are meeting the needs of customers based on what they're driven, what they're asking for. We also want to make sure that we're driving things that are population sized so that we're not over building or under building for the community.

We're not going to go through all of these projects. These are just some current self projects that we're working on that are driven by what we've the community feedback, the customer feedback, we've heard. And the important thing to highlight is that none of these projects mean necessarily bringing people into clinic to generate revenue, or have more community more clinic visits. They are often providing services outside of the clinic, their prevention preventative in nature rather than being reactive or responsive. And they're really about building healthier communities and individuals in a way that is, is more convenient for our customer owners rather than having our customer owner come here and do what we think is best for them so current projects that continually are driven by the community

At the end of all of this we love to celebrate and just acknowledge the work that we're doing because we are proud that Alaska native people have taken control and ownership and really driven this high quality healthcare system. We're committed to this journey. Here’s a quick slide that you can see about some upcoming events. If you wanna learn more, but we're gonna wrap it up and I open it to questions.

Sorry. I felt like I was fast at the end, but wanted to make sure we have questions.

Melissa Merrick:

Doug, there was one about money, and I put it in the chat. I'm just gonna say real quickly about 40% of our money is what's called Indian Health Service Monies, the Federal Government giving us like a block grant once a year that we can use pretty much how we want. So that's nice, flexible money. And then just over 50% is fee for service. So, we see someone, we submit a bill to various range of insurance payers, and then we get paid. And somewhere between 5 and 10% every year is grants philanthropy. You know, just chasing money every way. We can chase money, and our spend is about 2 thirds of the national average spend per person per year. It should be 3 times the national average, because we have triple the complexity in terms of environmental cofactors, historical trauma effects, and just the logistics of a very big geography so we really should be 3 times the national average. Instead, we're about two-thirds of national average and someone needs to know what that actually means in dollars. It's about $7,000 per person per year that we spent.

Chelsea Ryan:

But remember, we're like the most expensive place in the whole United States to live because we're far away from everything and everybody and we have massive geography. Okay, we're using Cerner at this time. and then I know for our behavioural services partners they use different ones. Another question I have here is to Doug or Melissa. Do you have any information on how your service has contributed to hospital avoidance?

Douglas Eby:

Yeah, in that initial data at the beginning, somewhere we've dropped emergency use and hospital admissions by big, very big number somewhere around half of what it was before we started doing this. Now, some of that's just changing in healthcare across the country but at least half of that reduction is probably directly attributable to better chronic condition management and just straight up hospital avoidance. We benchmark all our data against national best practices and so forth.

Chelsea Ryan:

Yeah, sorry. I was just gonna add that there's times, where our primary care teams where we're actually having to go, men's customers who are on the phone like, no, you actually need to go to the emergency department. It's sort of funny, because they just get so used to having that same day access their relationship with their team, that as you're doing a telephone triage. It's Yup, you need to go there, and we are happy to see you after but there's certain things we cannot do in primary care.

Melissa Merrick:

and I was just gonna add that to 2 different perspectives. One of the metrics we built year a couple of years ago was looking at how many impaneled customers are going to the emergency room. And so we looked at that on a regular basis. I think we built it with this idea that we were gonna see a lot more and it actually, we still monitor it but we're not seeing as many people going to the emergency room as Chelsea described. It's still a helpful metric to Monitor but I think when we saw the trending data we were, we're like, Oh, it's more people are coming into primary care which made sense. We still felt like, maybe that wasn't true. And then, we also have a team that is really focused on their intensive case management team really focused on outreach in the community and helping support, connecting back to primary care for those customer owners whose tendency is to use the emergency room as their primary care team, and so really, intentionally trying to build that back to the the Hub primary care.

Chelsea Ryan:

Absolutely. So, another question I have here is, how is maternity care provided specifically birthing services?

Douglas Eby:

So not sure we’re the international superstars on this. We do have a very midwife centric prenatal and birthing process so pretty much all of our prenatal and act and lower risk birthing is done by certified nurse midwives backed up by OBGY. N. Obstetric gynecology. Physicians who then help manage the higher risk, and we do have the very high end people, the maternal fetal medicine, perinatology, people. It's all part of a seamless system that works together as one system for everybody. Villages are a challenge. Historically, there were Indigenous birth workers and villages that's pretty much gone away, and the majority of people also want the safety of a hospital delivery in case something goes wrong. Unfortunately, a lot of our mothers from villages come and spend the last month of their pregnancy here in the city, and then give birth here, and then go back home.

There are some regional smaller regions around the State that that do their own birthing but even there, if you're from a small village, you go to the regional centre and give birth there. If you're high risk, you're in here in the city, and we do all the antennatal tech. We're very high tech. We have an almost 200 bed hospital with a neonatal, intensive care, pediatric, intensive care, adult intensive care. We're a level 2 trauma centre so we do all that super high end stuff as well, us and our tribal partners. We have a partner organization called the Alaska Native Tribal Health Consortium, of which we are part of the consortium, and then we partner with them around the hospital in more intensive care kind of stuff.

Chelsea Ryan:

Yeah. Doug mentioned about how there were traditional birth workers and I can just share that in my own family. My mom and her sister were the only ones who were not delivered in our home village because, the local midwives our birth workers knew that there were twins. She was flown, basically on a mail plane down the river to the biggest location that had a bigger clinic and was delivered there. But there is a resurgence right now. We have a grassroots organisation based out of anchorage called the Alaskan Native Birth workers and they're doing really incredible work. I know that as a campus, we're supporting them with space for them to hold different trainings and again, it's that example of self-determination where they wanna stay grassroots. They wanna stay. Community led community driven.

They're doing indigenous doula trainings, indigenous breast feeding trainings. They were just up in gnome, which is about an hour and a half flight out of anchorage to do a birth worker training there as well, and so really trying to have that resurgence what that kind of support looks like and feels like in conjunction with Western medicine and the safety standards that a lot of people are looking for. There's another question here about in the Northern Territory. We have aboriginal health workers and practitioners both come with a cultural lens. Both have national standards, and currently the practitioner is regulated. Do you have something similar?

Douglas Eby:

Yeah. So, the community health aids I was talking about are almost all Alaskan native, not 100, but probably 80, are Alaskan native people. We prefer to hire from within the village and then train. So rather than have city people try to be bribed to go live in rural areas identify rural people who want to live there and then get them the training. So, our comparison, or what are called a community health workers, our community health aids and they have 5 levels of training so there's level 1, 2, 3, 4, and then very advanced community health practitioner level one and 2 have to connect with the physician on the phone or video almost every time they see someone. By the time you're level 3 and 4, you're practicing mostly independently. By the time you're community health practitioner you're practicing very independently, prescribing your own medications and so forth. They have a licensing process with the State of Alaska and we, as a system, wanted to do that because it allows them to submit bills and get paid. The community health aid gets paid. I think it's right at 80% of what a physician gets paid in terms of for service. You submit a bill. The payment is about 80% of what the physician would get paid so that's very good. The way we got that was by putting in place a a certification and licensing process.

What are the same thing around behavioural health aids? There's levels of training for behavioural health aids. Then the dental health aids go through 2 years of training, and they can actually drill and fill but fillings in teeth and do a lot of the other cleaning and preventive things around teeth and oral health as well.

Chelsea Ryan:

Umhm, I'm excited about the oral health advancements that we've made over the years. So here's a question, Melissa, you can field this one. How do we incorporate clinical research or trials into services.

Melissa Merrick:

So great question. So, we do have a small research department and we actively partner with other tribal research entities, including hospital systems or education systems. We are very intentional about our research design and what it is that we're wanting to research. We seek feedback from the community around, what are the research projects that we're interested and focused on. Most importantly, we are very intentional about how that looks and feels and always have, customer owner voice. In that process. Alaska, native American Indian people have a history of being research or tested on. The last thing we want to do is continue to support or to continue to create an environment that feels not good to folks. We have a very robust tribal Irb, which is a research review process that approves research projects. And so we do some small clinical trials. But very intentionally and with a lot of planning and thought.

Chelsea Ryan:

Thank you. We have about 3 min. I just wanna make a plug, Erica put in the chat a link to provide us feedback on this webinar. We would love to hear you know how this went, what you took away from it, or what we could do better, as we present to others trying to catch up in the chat here. Oh, perfect! Doug is on a roll, so he's answering some of them.

Melissa Merrick:

Just on that back to the health aid. I know Doug mentioned that. There is a certification. That is locally tribal, but also supported by the State, and that also allows us to get some reimbursement from the State for that service. I think that's important, because the State of Alaska and Medicaid, which is one of our Federal payers, has recognised the importance of the community health aid and the behavioural healthy work. There is as you know, certain billing codes that we can act, that we can utilise for some third party reimbursement.

Chelsea Ryan:

So, here's I think, probably our last question, is, how do you actually reach meaningful community engagement when the system still thinks that engagement of communities is the same as engagement with communities or leadership by communities.

I'm just kind of processing. That question happens in a lot of ways.

Douglas Eby:

So I'll take a first shot. Then either one of you want to add. In my 30 years of working here, I think this is the thing that we do most differently from anywhere else, which is, we have literally 2025 different ways that we continually listen to the voice of the community. And we have structured ways from advisory councils to what we call joint operating boards but also about 60, depending which program 60 to 70% of our staff are Alaska native people, and like with Chelsea we encourage every single one of them to bring their families. Opinions, you know, work here all day, go home, have the kitchen table conversation, and bring that kitchen table conversation back to work with you the next day. This whole thing of keeping distance between your personal life and your work life, especially if you're Alaskan native. We're not interested in that. It's all life.

We want you to bring all of your conversations and opinions and experiences. We want to hear about what happened to your auntie and your uncle and your cousin. We want to hear that pissed off. We want to hear the happy and so, for example, anytime, we create a committees here. We want to make sure that you know at least half of that committee are Alaska native people who work here, and especially when we run improvement projects. We want the voices at the table to be if possible, entirely, but at least primarily Alaskan native people who work here and who don't work here. But if you work here in your Alaskan native, your job is to do your job, and also to be a voice for yourself, your family, your people in your community all day, every day, and that's built structurally into all the committees and advisory councils and join operating boards and all of that sort of thing. If you take the 20 most powerful people in the company with the biggest titles each of us spend somewhere between 20 and 40% of our work hours in listening mode. In some way with the community elders counsel, traditional healing counsels, youth councils people with lived experiences of all sorts. It's a continual immersion into the community. What the community likes doesn't. The other thing about improvement is like at one council meeting we'll get a bunch of advice, and then we'll go do something at the next council meeting. We'll say, here's what we heard. Here's what we did. What do you think of what we did? So it's a continual conversation, not an impersonal survey you get in the mail, or you make a suggestion, and you never know what happens. That's not good.

Ruth Stewart:

Okay, thank you all so much for what's been a really engaging conversation, thanks to all our registrants for joining and asking questions. I'd also like to thank all the staff behind the scene who made this webinar possible. In my office there is Katherine Logan, Karen Hinchy and Tanya Lindsey and we've all worked very closely with the team in the Southcentral Foundation, especially with Jake Johnson. So, thanks everyone. Look. If you've got any additional questions or would like more information on South central foundation, please contact Jake Johnson at JaJohnson@SouthcentralFoundation.com

We'll put the recording of this webinar on our web page for you to share and revisit. Please take a minute to provide feedback on today's webinar. The link is in the chat down the bottom of the page.  Thanks so much for joining us today.

Melissa Merrick:

Thank you very much. This wonderful panel. You've been great. You've been engaged. You've really answered so many questions. So thanks, each of you, Chelsea and Melissa and Doug.

Melissa Merrick:

Thank you. Thank you all. It's a pleasure.

Ruth Stewart:

Bye everyone.

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