1. Healthcare 3.0 The Nuka System of Care Doug Eby, VP of Medical Services Steve Tierney, Medical Director/CMIO Copyright © 2011 Southcentral Foundation. All Rights Reserved. NOTICE: Unless otherwise indicated, this work represents copyrighted material protected by United States and international law. This work may not be used, reproduced, downloaded, disseminated, published, transferred or transmitted, in whole or in part, in any form or by any means, electronic or mechanical, including photocopying, recording or information storage and retrieval, except with the express written permission of the publisher. This work may not be edited, altered, or otherwise modified, in whole or in part, except with the express written permission of the publisher.

2. 3 Sections of Content 1.Basic history and approach of SCF and Stages of SCF’s PCMH evolution 2.Tools to manage Team Dynamics and Population Modeling 3.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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

3. 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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

4. Key Points Shared Responsibility Commitment to Quality Family Wellness Copyright © 2011 Southcentral Foundation. All Rights Reserved.

5. Relationships between customer-owner, family and provider must be fostered and supported Emphasis on wellness of the whole person, family and community (physical, mental, emotional and spiritual wellness) Locations convenient for customer-owners with minimal stops to get all their needs addressed Access optimized and waiting times limited Together with the customer-owner as an active partner Intentional whole-system design to maximize coordination and minimize duplication Outcome and process measures continuously evaluated and improved Not complicated but simple and easy to use Services financially sustainable and viable Hub of the system is the family Interests of customer-owners drive the system to determine what we do and how we do it Population-based systems and services Services and systems build on the strengths of Alaska Native cultures Operational Principles Copyright © 2011 Southcentral Foundation. All Rights Reserved.

6.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

7.  Over 25 years of history  Innovative, relationship based, customer driven systems  1,500 staff – 140,000 statewide clients  55,000 local clients including 10,000 in over 50 remote villages  Expanding local population (7%/yr) Southcentral Foundation Copyright © 2011 Southcentral Foundation. All Rights Reserved.

8.  Medical Services – Primary Care, Women’s Health, Pediatrics, Optometry  Dental  Behavioral Health – clinics, residential treatments, after-care, youth, elders  Family Wellness Warriors – abuse and neglect treatment and prevention  Tribal Doctors and Traditional Services  Chiropractor, massage, acupuncture Southcentral Foundation Copyright © 2011 Southcentral Foundation. All Rights Reserved.

10.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

11.  Defining the purpose – relationship over time  Understanding complexity science - principles  Moving 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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

12. 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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

13.  Outcome not income  Person not disease  Population not process  Service not practice Approaching the Philosophic Thought Process of Redesign Copyright © 2011 Southcentral Foundation. All Rights Reserved.

14. 1.Never disturb the workforce without clear cause and plan. No plan is better than a bad plan 2.Always design for what happens 85% of the time for 85% of events 3.Always create methods to identify exceptions to “85/85” so appropriate adjustments can occur 4.Always design second and third level plans for exceptions to the “85/85 rule” rather than primarily over over-designing for all events 5.Always analyze before repair, look for patterns or clusters, remember rule #1 6.Always when improving, extremes of performance are more instructive than averages to quantify progress. Segmentation is critical, trends are more important than current performance 7.Never train entire groups when you can target only those at variance 8.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 it 10.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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

15.  Segmented measurement by individual  Integration of traditionally separate work types  Team dynamic optimization  Including Customer as an equal partner  Data Modeling and pattern recognition  “Smart Systems” that suggest both diagnoses and plans Stages of PCMH Evolution (not to be confused with levels) Copyright © 2011 Southcentral Foundation. All Rights Reserved.

16.  Changing from organizational level data to segmentation down to the work team or individual level.  Operational and business model unchanged  Measurement 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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

17.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

18.  Shift to team dynamics and team skill building  Move 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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

19.  Recognizing the value of the customer  Understanding 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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

20.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

21.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

22. Team Tools and Approaches Copyright © 2011 Southcentral Foundation. All Rights Reserved.

23.  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? Copyright © 2011 Southcentral Foundation. All Rights Reserved.

24. Control: Who really makes the decisions Acuity “Control” The “System” Customer-owner/Family 0 LowHigh 100 1.Control – who makes the final decision influencing outcome? 2.Influences – family, friends, co-workers, religion, values, money 3.Real opportunity to influence health costs/outcomes – influence on the choices made – behavioral change 4.Current model – tests, diagnosis, treatment (meds or procedures) Copyright © 2011 Southcentral Foundation. All Rights Reserved.

25. Low High complexity - variables Complexity Low High Certainty or Agreement Protocols & Stds Chaos Some simple rules for improvement Experimenting Get together and have dialogues An allowing/positive environment Multidimensional improvements with target focus Creativity complexity diagram Copyright © 2011 Southcentral Foundation. All Rights Reserved.

26.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

27.  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… Copyright © 2011 Southcentral Foundation. All Rights Reserved.

28. Traditional Methods of Managing Work Flow

29. Parallel Work Flow Redesign Copyright © 2011 Southcentral Foundation. All Rights Reserved.

30.  What are the logical consequences of thinking differently? Team Members Methods of Communications Physical Space Payment Methodology Core Skill Set Training and Education Consequences… Copyright © 2011 Southcentral Foundation. All Rights Reserved.

31.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

32.  Logical Extensions of this… Rethinking Specialist roles Rethinking Hospitals ‘Pull Discharges’ Weaving Communication and services into THEIR lives Consequences Copyright © 2011 Southcentral Foundation. All Rights Reserved.

33.  PCP - Primary Care Provider-DOC, NP/PA  Nurse Case Manager  Case Management Support  Certified Medical Assistants  Behaviorists  Dieticians The Integrated Care Team Copyright © 2011 Southcentral Foundation. All Rights Reserved.  Pharmacist (partially implemented)  Nurse Midwife (partially implemented)  Coverage NP/PA/CM’s  Co-located Psych (pending)  Coders, Data entry, etc.  Front Desk

34.  Up front training for CMAs and Admin Support  Native professional development  Hiring Practices – Same day, behavioral  Orientation and Mentoring intentionally  Employee Development Center  PAP’s, Job progressions, career ladders  Summer and Winter Interns  KEY – All staff ‘expert” in improvement Workforce Development Copyright © 2011 Southcentral Foundation. All Rights Reserved.

35.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

36. The Nuka Method for Creating Change Practical Use of Tools for Managing and Coaching Teams Copyright © 2011 Southcentral Foundation. All Rights Reserved.

37.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

38.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

39.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

40. Core Concepts: W ork together in relationship to learn and grow E ncourage understanding L isten with an open mind L augh and enjoy humor throughout the day N otice the dignity and value of ourselves and others E ngage others with compassion S hare our stories and our hearts S trive to honor and respect ourselves and others Copyright © 2011 Southcentral Foundation. All Rights Reserved.

41.  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 employees  Proactive in making a change on major issues facing our community: Domestic Violence, Sexual Abuse/Assault and Neglect So Why FWWI and Core Concepts Training?

42.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

44.  Establish a safe environment  Build Trust  Lay the foundation for full participation and interaction  Get acquainted Learning Circle Guidelines Copyright © 2011 Southcentral Foundation. All Rights Reserved.

45.  Go off duty  Appropriate behaviors  Expectations of confidentiality  Attendance  Stories and responding to Learning Circles  Self-Care Care Team availability Core Concepts Boundaries Copyright © 2011 Southcentral Foundation. All Rights Reserved.

46.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

47.  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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

48. 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. Copyright © 2011 Southcentral Foundation. All Rights Reserved.

49.  Healthy Responses to a Story  Match your response to the level of story that is shared  Give Authentic Responses  Speak from your heart  Give responses that should make it safe for the person to tell more of their story  Keep responses without judgment Responding to Story Copyright © 2011 Southcentral Foundation. All Rights Reserved.

51. The shape you are in exercise Copyright © 2011 Southcentral Foundation. All Rights Reserved.

52. Mental Models  Mental 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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

53. Mental Model - Marriage  Some think Ball and Chain Shackles Prison No more dating  Some think Security Celebration Happiness Life Partner Copyright © 2011 Southcentral Foundation. All Rights Reserved.

54. 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. Copyright © 2011 Southcentral Foundation. All Rights Reserved.

55. Left Hand Column Activity  Left –Hand Column What I thought and felt but didn’t say  Right-Hand Column What was said (actual dialogue) Copyright © 2011 Southcentral Foundation. All Rights Reserved.

57. Dialogos Int’l LLC & SOL, Cambridge, MA Quality Interactions 4 Player Model Copyright © 2011 Southcentral Foundation. All Rights Reserved.

58. Kantor’s Four Player System Follow Without Followers there is no Completion Bystand Without Bystanders there is no Perspective Move Without Movers there is no Direction Oppose Without Opposers there is no Correction © 1995 David Kantor Copyright © 2011 Southcentral Foundation. All Rights Reserved.

59. Dialogos Int’l LLC & SOL, Cambridge, MA Bystander Opposer Follower Mover Perspective Patience Preservation Moderation Self-Reflection Correction Courage Protection Integrity Survival Completion Compassion Loyalty Service Continuity Direction Discipline Commitment Perfection Clarity Action Intends: Disengaged Judgmental Deserting Withdrawn Silent Critical Competitive Blaming Attacking Contrary Placating Indecisive Pliant Wishy-Washy Over-accommodating Omnipotent Impatient Indecisive Scattered Dictatorial But sometimes comes across as: Bystander Opposer Follower Mover Action Positions © 1995 David Kantor Copyright © 2011 Southcentral Foundation. All Rights Reserved.

60. 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? Copyright © 2011 Southcentral Foundation. All Rights Reserved.

61. 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) Copyright © 2011 Southcentral Foundation. All Rights Reserved.

62. 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. Copyright © 2011 Southcentral Foundation. All Rights Reserved.

63. Dialogos Int’l LLC & SOL, Cambridge, MA Providing Space – when One or More Dynamic is Missing 4 Player- Role IntentIf 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?” Copyright © 2011 Southcentral Foundation. All Rights Reserved.

65. CDR Profile Copyright © 2011 Southcentral Foundation. All Rights Reserved.

66. 5 Dynamics Dimensions  Explore  Excite  Examine  Execute  Evaluate Copyright © 2011 Southcentral Foundation. All Rights Reserved.

67. 5 Dynamics Person to Person Copyright © 2011 Southcentral Foundation. All Rights Reserved.

68. 5 Dynamics Team Copyright © 2011 Southcentral Foundation. All Rights Reserved.

69. New Ways of Thinking About Customer and Staff Interactions DiabetesDepressionCVD 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 Copyright © 2011 Southcentral Foundation. All Rights Reserved.

72. Thank You! Qaĝaasakung Aleut Quyanaq Inupiaq Háw'aa Haida ‘ Awa'ahdah Eyak Mahsi' Gwich’in Athabascan Igamsiqanaghhalek Siberian Yupik Tsin'aen Ahtna Athabascan T’oyaxsm Tsimshian Gunalchéesh Tlingit Quyana Yup’ik Chin’an Dena’ina Athabascan Quyanaa Alutiiq Copyright © 2011 Southcentral Foundation. All Rights Reserved.

73. Questions? Please contact: Erica Srisaneha Southcentral Foundation 907-729-8608 esrisaneha@scf.cc Or log onto our website at www.scf.cc/nukawww.scf.cc/nuka Copyright © 2011 Southcentral Foundation. All Rights Reserved.