Healthcare 3.0 The Nuka System of Care
Doug Eby, VP of Medical Services
Steve Tierney, Medical Director/CMIO
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3 Sections of Content1. Basic history and approach of SCF and Stages of
SCF’s PCMH evolution2. Tools to manage Team Dynamics and Population
Modeling3. Understanding Interactive use of Team Tools
Goal is to get clarity about where your system is and what steps you might take to create change
Learning Objectives
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Vision A Native Community that enjoys physical, mental, emotional and spiritual wellness Mission Working together with the Native Community to achieve wellness through health and related services
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Key PointsShared ResponsibilityCommitment to QualityFamily Wellness
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Relationships between customer-owner, family and provider must be fostered and supportedEmphasis on wellness of the whole person, family and community (physical, mental, emotional and spiritual wellness)L ocations convenient for customer-owners with minimal stops to get all their needs addressedAccess optimized and waiting times limitedTogether with the customer-owner as an active partnerIntentional whole-system design to maximize coordination and minimize duplicationOutcome and process measures continuously evaluated and improvedNot complicated but simple and easy to useS ervices financially sustainable and viable Hub of the system is the familyInterests of customer-owners drive the system to determine what we do and how we do itPopulation-based systems and servicesS ervices and systems build on the strengths of Alaska Native cultures
Operational Principles
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If you could own completely your own healthcare system, what would you do –as a customer-owner?
We had that choice – and chose to fundamentally rethink and redesign every single thing in the entire system.
We kept the best that modern medicine has to offer and we kept the medical professionals, but we redefined the fundamental understandings, redefined the ‘core concepts’, and changed dramatically the whole system platform.
Customer Control at both the macro and micro level – shared partnership, commitment to quality, family wellness.
Customer Control
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Over 25 years of history Innovative, relationship based, customer driven systems
1,500 staff – 140,000 statewide clients55,000 local clients including 10,000 in over 50 remote villages
Expanding local population (7%/yr)
Southcentral Foundation
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Medical Services – Primary Care, Women’s Health, Pediatrics, Optometry
DentalBehavioral Health – clinics, residential treatments, after-care, youth, elders
Family Wellness Warriors – abuse and neglect treatment and prevention
Tribal Doctors and Traditional ServicesChiropractor, massage, acupuncture
Southcentral Foundation
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Evidenced-based generational change reducing family violence
50% drop in Urgent Care and ER utilization 53% drop in Hospital Admissions 65% drop in specialist utilization 20% drop in primary care utilization 75-90%ile on most HEDIS outcomes and quality Childhood immunization rate of 93% Diabetes with 50% of HbA1c below 7% Employee Turnover rate less than 12% annualized Customer and staff overall satisfaction over 90% In an urban Alaska Native community with huge challenges
Why Listen to our Story
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Defining the purpose – relationship over timeUnderstanding complexity science - principlesMoving from product to service as the fundamental base of entire system
Optimized primary care with redefined entire system on that ‘new’ backbone/platform
Customer driven design – reallocation of power and control at every level
Optimizing messy human relationships
The SCF Nuka System
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Attempting to isolate a single intervention as the approach to change within a complex dynamic system assumes all other processes, events and participants remain static over time. Is that a reasonable expectation?
Risk of Reductionism
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Outcome not income Person not disease Population not process Service not practice
Approaching the Philosophic Thought Process of Redesign
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1.Never disturb the workforce without clear cause and plan. No plan is better than a bad plan2.Always design for what happens 85% of the time for 85% of events3.Always create methods to identify exceptions to “85/85” so appropriate adjustments can occur4.Always design second and third level plans for exceptions to the “85/85 rule” rather than primarily over over-designing for all events5.Always analyze before repair, look for patterns or clusters, remember rule #16.Always when improving, extremes of performance are more instructive than averages to quantify progress. Segmentation is critical, trends are more important than current performance7.Never train entire groups when you can target only those at variance8.Always intervene from the “back not the front” where possible. Identify those doing well and recall rule #1. Always fix what is broken. Always spread what works 9.Always, the first step in change is to design the ability to measure. Never intervene without it10.Never build a pathway without attaching a measure that can be applied to the entire denominator without reviewing charts or requiring individual case review. Pathways are not measures. They “suggest” visit based, provider driven decisions.
10 Tips for Redesign
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Segmented measurement by individual Integration of traditionally separate work types
Team dynamic optimization Including Customer as an equal partnerData Modeling and pattern recognition “Smart Systems” that suggest both diagnoses and plans
Stages of PCMH Evolution(not to be confused with
levels)
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Changing from organizational level data to segmentation down to the work team or individual level.
Operational and business model unchangedMeasurement is segmented but not responsibility for measurement which still stays with leadership
Resources are still allocated and analyzed from a system wide level
Leadership still focused on system wide measurement
Stage 1 PCMH
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Integrating teams with roles traditionally separated in older work systems
More customer focused work flow prospective Usually accompanied by changes in floor plan and office space
Often results in more wide variation in performance between teams
Professional staff often not prepared or trained to work in interdisciplinary environment
Stage 2 PCMH
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Shift to team dynamics and team skill buildingMove away from traditional workflows with visit basis or clinical focus toward team awareness and optimization
Reorganize data to discover variance in team performance and spend efforts to understand reasons around variance
Focus more on outcome as opposed to process
Stage 3 PCMH
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Recognizing the value of the customerUnderstanding patterns of use and non use are instructive and are comments on the ease, effectiveness and satisfaction with your larger system
Adding infrastructure to learn directly from the customer base, more than just advisory or focus groups
Stage 4 PCMH
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Data modeling for pattern recognition as a tool/strategy
Segmenting costs and work volume by methods other than disease
Adding new methods of intervention to address variance within new segments
Reorganizing workforce to more effectively manage newly exposed performance gaps
Stage 5 PCMH
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Using previously identified patterns to trigger smart systems that suggest best approach or plan
Incorporating these smart systems into infrastructure available to both consumers and staff
Stage 6 PCMH
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Team Tools and Approaches
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What are we really trying to accomplish – optimal individual health at a population level, with a good experience of care, and at an affordable cost – the Triple Aim
Has the 75 years of the Medical Model gotten us there? Yes – Trauma, Infectious disease, broken parts – fixing
and eradicating No – Living with long tern health challenged and
conditions – now 60-70% of healthcare cost – and growing
Backing Up – Purpose?
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Control: Who really makes the decisions
Acuity
“Control”
The “System”
Customer-owner/Family
0 Low High
100
1. Control – who makes the final decision influencing outcome?2. Influences – family, friends, co-workers, religion, values, money3. Real opportunity to influence health costs/outcomes – influence on
the choices made – behavioral change4. Current model – tests, diagnosis, treatment (meds or procedures)
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Low High complexity - variables
Complexity
Low
High
Cer
tain
ty o
r A
gre
emen
t
Protocols & Stds
Chaos
Some simple rules for improvement
Experimenting
Get together and have dialogues
An allowing/positive
environment
Multidimensionalimprovements with
target focus Creativity
complexity diagram
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Why do people come to us – concerns from new signs and symptoms, changes to be managed, interpreting confusing messages, and supportive coaching advice, medications
So, how can we understand what makes up our work - • Diagnosis• Prescribing• Procedures• Teaching, Coaching, Advising• Encouraging• Calming, soothing, reassuring
OK – What To Do
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Of that list – what needs to be handled in person, video, email, text, phone?
How do people handle other parts if their lives?Only two areas left not revolutionized by the Digital-Software Revolution – Healthcare and Education.
How would Facebook or Google design how to address the reasons people seek out healthcare professionals?
So, Then, What To Do…
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Provider
Chronic Disease
Monitoring
Customer
Preventive Med
Intervention
Mental Health
Provider
Referral to Specialist
after Assessment
Medication Refill
New Acute Complaint
Customer Customer
CustomerCustomer
CustomerCustomer
Customer
Certified Medical
Assistant
Case Manager
Test Results
Customer
Health Care
Support Team Dietitian
Clinical Pharmacist
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Traditional Methods of Managing Work Flow
Parallel Work Flow Redesign
Health CareSupport
Team
Chronic Disease Monitoring
Preventive Med
Intervention
Certified Medical Assistant
Clinical Pharmacist
Medication Refill
Undiagnosed or Changing New
Consumer Concern
ProviderCase
Manager
Management of Study /Test Results Info
In Clinic Point of Care
Testing
Chronic Disease
Compliance Barriers
Acute Mental Health
Concern
Customer
Customer
Customer
CustomerCustomer
CustomerCustomer
Customer
Customer
Dietitian
Behavioral Health
Consultant
Customer
Customer Customer
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What are the logical consequences of thinking differently? • Team Members• Methods of Communications• Physical Space • Payment Methodology• Core Skill Set• Training and Education
Consequences…
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In place at SCF…• De-Officing everyone – intentionally designed team spaces
• Elimination of Nurses Stations• De-medicalizing encounter spaces• Integrated Care Teams – Whole person, family• Virtual visits
Consequences
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Logical Extensions of this…• Rethinking Specialist roles• Rethinking Hospitals• ‘Pull Discharges’• Weaving Communication and services into THEIR lives
Consequences
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PCP - Primary Care Provider-DOC, NP/PA
Nurse Case Manager Case Management
Support Certified Medical
Assistants Behaviorists Dieticians
The Integrated Care Team
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Pharmacist (partially implemented)
Nurse Midwife (partially implemented)
Coverage NP/PA/CM’s Co-located Psych
(pending) Coders, Data entry, etc. Front Desk
Up front training for CMAs and Admin SupportNative professional development Hiring Practices – Same day, behavioralOrientation and Mentoring intentionallyEmployee Development CenterPAP’s, Job progressions, career laddersSummer and Winter InternsKEY – All staff ‘expert” in improvement
Workforce Development
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Extensive training and formal mentor systems for front desk, CMA’s. others in place for sometime already
Now expanding to physicians, nurses, other clinical staff – Partially implemented only at present
Commitment to extensive training by outside mentoring systems and experts – deeply incorporated into all of SCF over time
One mentor for every three clinical staff
Mentors – Clinical Mentors
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The Nuka Method for Creating Change
Practical Use of Tools for Managing and Coaching
Teams
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Identify key strategies in using effective communication tools that can improve adult learning in meetings and open forums
Apply effective listening skills and recognize the importance of maintaining correct interpretations of an individual’s communication intentions
Objectives
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Intro to Core Concepts – The Power of Sharing Story• Connection to your story• Respond to people from your heart• Walk beside others with empathy
Core Concepts
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Guiding principles each employee should use in every interaction in order to create healthy relationships
Every person has a story, that story influences both prospective and reactions
Understanding that story offers the opportunity to identify and understand both barriers and opportunities for change
Definition of Core Concepts
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Core Concepts: Work together in relationship to learn and grow
Encourage understanding
L isten with an open mind
L augh and enjoy humor throughout the day
Notice the dignity and value of ourselves and others
Engage others with compassion
Share our stories and our hearts
Strive to honor and respect ourselves and others
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Better at communicating and working together with our customer-owners and each other in order to achieve our mission and vision
Increase in customer-owner satisfaction Increase in the climate of trust for employeesProactive in making a change on major issues facing our community: Domestic Violence, Sexual Abuse/Assault and Neglect
So Why FWWI and Core Concepts Training?
Core Concepts Training is about a set of tools to enable employees, wherever they are on their own journey, to increase their capacity to relate to those with whom they work
Better relationships = healthy customer-owners AND healthy employees
Bottom Line
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Establish a safe environmentBuild Trust Lay the foundation for full participation and interaction
Get acquainted
Learning Circle Guidelines
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Go off dutyAppropriate behaviorsExpectations of confidentialityAttendance Stories and responding to Learning CirclesSelf-Care
• Care Team availability
Core Concepts Boundaries
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A record or narrative description of past events
In Alaska Native culture sharing story is done to show values, pass on skills, and in some instances, show why and how something is or came to be
What is a Story
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A story can be shared at various levels or depths
30,000 foot – i.e., what happened while you drove to work
10,000 foot – i.e., a difficult situation getting along with coworkers or a friend
Ground Level or Below – i.e., a profound moment or memory that affects you today
Levels of a Story
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Sharing your Story The depth of story you share is always up
to you.
You have the permission to go where ever you are comfortable going.
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Healthy Responses to a StoryMatch your response to the level of story that is shared
Give Authentic ResponsesSpeak from your heartGive responses that should make it safe for the person to tell more of their story
Keep responses without judgment
Responding to Story
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The shape you are in exercise
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Mental ModelsMental Models are established by past events, experiences, media and other messages we receive, and serve going forward as filters through which we observe, interpret and respond to the world
They shape what we see and hear, what we feel and what we do
Mental Models give birth to stereotypes
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Mental Model - Marriage
Some think• Ball and Chain• Shackles• Prison• No more dating
Some think• Security• Celebration• Happiness• Life Partner
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Left-Hand Column
A method developed by Chris Argyns and David Schoon to reflect on the quality of a
conversation by analyzing it from two perspectives.
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Left Hand Column Activity
Left –Hand Column• What I thought and
felt but didn’t say
Right-Hand Column• What was said
(actual dialogue)
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Dialogos Int’l LLC & SOL, Cambridge, MA
Quality Interactions 4 Player Model
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Kantor’s Four Player System
FollowWithout Followersthere is no Completion
BystandWithout
Bystandersthere is no
Perspective
MoveWithout Movers
there is no Direction
OpposeWithout Opposers
there is no Correction
© 1995 David Kantor
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Dialogos Int’l LLC & SOL, Cambridge, MA
Bystander
Opposer
Follower
Mover
PerspectivePatience
PreservationModeration
Self-Reflection
CorrectionCourage
ProtectionIntegritySurvival
CompletionCompassion
LoyaltyService
Continuity
DirectionDiscipline
CommitmentPerfection
Clarity
Action Intends:
DisengagedJudgmentalDesertingWithdrawn
Silent
CriticalCompetitive
BlamingAttackingContrary
PlacatingIndecisive
PliantWishy-Washy
Over-accommodating
OmnipotentImpatientIndecisiveScatteredDictatorial
But sometimescomes across as:
Bystander
Opposer
Follower
Mover
Action Positions
© 1995 David Kantor
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Dialogos Int’l LLC & SOL, Cambridge, MA
Exercise - 4 Player Model
1. What role are you most comfortable in? OR in which role do you find yourself most often? (home and work)
2. What role are you least comfortable in ? OR in which role do you find yourself the least often or have to really care before you go into that role? (home and work)
3. What role do you want to work on improving? What can your learning circle partners help you work on in the next few days?
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Dialogos Int’l LLC & SOL, Cambridge, MA
Features of Stuck Groups & Teams Individuals get locked into a single action
Opposers are punished by the group, or they dominate There are no strong Movers, or no one Follows a move. The Bystander is disabled. Individuals attach double messages to their moves Ritualistic and unproductive patterns of behavior prevail The team is unable to reach closure and produce results Lack of capability or flexibility to engage in all four
action behaviors Individuals gravitate to favorite behaviors (and are type
case in roles by others)
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Dialogos Int’l LLC & SOL, Cambridge, MA
Features of Balanced Groups & Teams Capability to engage in all four actions (move,
follow, oppose, and bystand) in observable balanced sequences.
Individuals have the flexibility to engage in more than one of the behaviors.
The group and individuals do not get caught in repetitive or ritualized patterns of behavior.
The group has an active, enabled bystander function which helps it inquire and stay unstuck.
People in the group are able to make clear, rather than mixed or ambiguous moves.
The group is able to reach closure and produce results.
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Dialogos Int’l LLC & SOL, Cambridge, MA
Providing Space – when One or More Dynamic is Missing
4 Player-Role
Intent If I want to take on role, then I might say
If I want to get someone to take the role, then I might say
Move Provide direction “I think that we should XX, John, would you…”
“John, what do you think we should do?”
Follow Commit to trying another’s direction
“That is a great idea! How can I help?”
“How can we support Peter’s suggestion?”
Oppose Raise differences for purposes of testing
“An alternative approach might be to…”
“Does anyone see anything in this that might not work?”
Bystand Test your view of what is happening
“I’ve noticed that we’ve been circling the same topic for some time. Perhaps we want to…”
“What are we overlooking?”
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CDR Profile
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5 Dynamics Dimensions
Explore Excite Examine Execute Evaluate
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5 Dynamics Person to Person
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5 Dynamics Team
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New Ways of Thinking About Customer and Staff
InteractionsDiabetes Depression CVD
Struggling Alone, 20-45 y/o single parent not employed
Communication and interaction strategy based on risk, cost and level of control
Thriving Alone, 20-35y/o single no dependent, employed
Urban Cliff Climbers, 20’s single and working, multifam house
Retired in Suburbs
55+ often couples in large SF homes
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Thank You!
Qaĝaasakung
Aleut
QuyanaqInupiaq
Háw'aa Haida
‘Awa'ahdah
EyakMahsi'Gwich’in
Athabascan
Igamsiqanaghhalek
Siberian Yupik
Tsin'aenAhtna Athabascan
T’oyaxsmTsimshian
Gunalchéesh Tlingit
QuyanaYup’ik
Chin’anDena’ina Athabascan
QuyanaaAlutiiq
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Questions?Please contact:
Erica SrisanehaSouthcentral [email protected] log onto our website at www.scf.cc/nuka
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