An Embedded Approach to Engaging Community Members: Lessons from Southcentral Foundation’s Nuka System of Care

Andrew Spencer, Center for Health Care Strategies

Engaging community members and patients to understand their perspectives and inform organizational and systems change is critical to advancing health equity. Beyond guiding quality improvement strategies that are more responsive to patient needs, building accountable relationships with communities served can help bridge gaps in trust between health care organizations and historically marginalized communities that have resulted from long-standing bias, stigma, and racist practices within the health care system. There is a clear association between higher levels of community engagement with local health care organizations and improved health outcomes.

Southcentral Foundation’s (SCF) innovative Nuka System of Care is a relationship-based and customer-owned approach that provides care to approximately 70,000 Alaska Native and American Indian people in Southcentral Alaska, including many with complex health and social needs. The Nuka System of Care places relationships with their patients  who they refer to as “customer-owners”  at the center of care delivery. 

The Better Care Playbook recently spoke with two SCF leaders to learn how SCF’s approach to customer-owner engagement has evolved over the years and the role it plays in improving care and advancing equity across their system. Karen McIntire has worked at SCF for 26 years, currently serves as Vice President of Workforce and is also a customer-owner within the health system. Steve Tierney, MD, a family physician by training, serves as Senior Medical Director of Quality Improvement and Chief Medical Informatics Officer at SCF. 

Q. What role does feedback from customer-owners play in SCF’s approach to providing care?

K. McIntire: SCF’s vision is a native community that enjoys physical, mental, emotional, and spiritual wellness, and we work together with our community to achieve wellness through health and related services. Expecting our employees to be in relationship with our patients, or as we call them, customer-owners, is a critical component of this vision.

And this is personal for me. This is the only health system that my sons have ever known, and Steve here is their primary care provider. I remember during the peak of the COVID-19 pandemic, they were texting Steve asking him “when can I hug my grandmother?” and so on. Our approach to provider and customer-owner relationships at SCF makes it easy for people to connect, ask questions, and be engaged in their health care.

S. Tierney: On the front end, we’ve worked hard to build a system where it is easy for customer-owners to see the same provider or provider team each time they come in. Provider teams can fluidly adjust to the individual’s needs and changes in their health or social context in real time, rather than follow a stepwise process checklist. I think all of this means that we hear customer-owners’ voices clearly because we know them like extended family.

Q. What are some of the mechanisms SCF uses to incorporate the perspectives of customer-owners into planning and health system change?

S. Tierney: Probably the most important way we incorporate the perspective of our community is through engagement with our board of directors, who are all community members and typically are users of the system. Through an annual set of conversations with our board, we commit to a number of objectives, which the executives’ pay and staff performance evaluations are ultimately based on. These objectives will range from measures that reflect our ability to be in touch with the community we serve  such as, percentage of employees that are tribal members or employee turnover rate  to clinical measures that we know are important to our community  such as, cancer screenings, pediatric immunization, or diabetes care.

Also, our ongoing day-to-day customer-owner satisfaction surveys are another key mechanism through which we listen to our community. Many health care organizations report annually on measures of patient satisfaction using Hospital Consumer Assessment of Healthcare Providers and Systems, which, for an organization our size, would yield about 300 surveys each year. Whereas with our approach, we receive 300 customer-owner surveys every day. This gives us considerably broader and deeper insight into our customer-owners’ perspectives than the typical industry standard. And these are results that we’ll always share with the board to inform performance objectives. 

K. McIntire: We have found that having ongoing and systematic processes to engage with customer-owners and the community is critically important, because the needs of the community are always changing. To that end, we also operate a hotline where individuals can provide feedback with a built-in system where managers are automatically emailed when a complaint is submitted related to their clinic.

And lastly, I would add that over 50% of our employees come from the community. This offers our teams direct insights into community perspectives outside of the systematic processes we have in place. It is not uncommon for individuals who work here to say, “Hey, my aunt is having problems, and we need to look at this,” as a way of identifying an opportunity for improvement.

Q. What sort of processes are in place to enable SCF to receive 300 patient satisfaction surveys a day?

S. Tierney: Every front desk at our service locations has an iPad with 12 core questions loaded onto it for customer-owners to respond to. These responses are linked to the date of the customer-owners’ visit and the provider team they saw, and immediately uploaded to our data cloud. By contrast, some of the major patient survey vendors out there might mail surveys to patients and you don’t know whether the responses are related to one of any number of different facilities they may have visited.

K. McIntire: Being able to attribute responses to specific providers is important. This makes the feedback highly actionable. Customer-owners are also prompted to input written answers if they respond with “neutral” or “dissatisfied” to any of the questions. We have found that we receive more information through these prompts alone than we ever previously received through mailed surveys.

Q. How does SCF ensure transparency in sharing customer-owner feedback with both staff and community members?

S. Tierney: Transparency is critical to how we ensure both accountability and a constant focus on quality improvement. We developed a scorecard featuring 12 key indicators accessible to all members of the organization, allowing them to view the metrics at both the provider team and individual provider levels. So, not only can individual providers track their own job performance, but anyone else in the organization can also see.

K. McIntire: I think this highly transparent approach does two things. Firstly, it promotes peer learning across the organization. If a team is struggling with managing blood pressure for its panel of customer-owners, it allows for that team to see which teams are doing better and reach out to them to see what they can learn. And secondly, it promotes healthy competition among teams. Nobody wants to see that their customer-owner engagement or diabetic eye exam scores are the lowest.

Q. What connections would you draw between SCF’s approach to centering the voices of customer-owners and broader efforts to advance health equity?

K. McIntire: Our organizational philosophy around integrating the voices of customer-owners unlocks innovative approaches to care that have improved health outcomes for the Alaska Native people we serve. One specific tool we use to center these voices in a way that leads to more equitable care is the power of storytelling. 

The sessions focused on storytelling are probably the most impactful part of our annual three-day “Core Concepts” organization-wide training. We pose the question to our team  “How do you get really good at learning someone else's story and sharing your own?”  and invite leaders and staff members from across the organization to share their own stories. Beyond being a great opportunity to facilitate community and trust within our organization, it equips our providers with the lens to start every encounter with a customer-owner with the understanding that people inevitably have a lot of things going on in their lives. Ultimately, this approach allows our providers to deliver the trust-based and individualized care needed to begin to undo the long history of health inequities and subsequent distrust in the health care system that has long impacted the communities we serve.

S. Tierney: We also ensure that most of our appointments are 30 minutes, rather than 10 or 15. More equitable care has to start with centering the human experience, and we have found that allowing our providers to spend more time with customer-owners allows for this. Knowing they have more time for each appointment, our providers can start by making eye contact and meeting customer-owners where they are at, rather than immediately going to a checklist or solely focusing on what they’ll add to the chart.