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October 2018 | Douglas K. Eby | Early View, Commentary
The research by Ford-Gilboe and colleagues1 in this issue of The Milbank Quarterly demonstrates that equity-oriented approaches to health care can lead to improved health outcomes, and this has been our experience at Southcentral Foundation (SCF) in Alaska as well. A key component of our approach at SCF has been the community taking ownership of health care at both a system and a personal/family level, thereby leading the way in determining how services are provided.
SCF is an Alaska Native–owned health care system responsible for providing health care and related services in partnership with approximately 65,000 Alaska Native and American Indian people in southern Alaska. Prior to 1998, health care for Alaska Native people was provided by the US government through the Indian Health Service (IHS). Even though the IHS staff were well intentioned, care was provided for Alaska Native people in the “usual” professional and institutional-centric medical approach. This resulted in little real understanding of the community, and services were less effective and did not address whole-person wellness. Most health outcomes were in the bottom 5th percentile for the United States.
In 1998, when Alaska Native people took full ownership of their own health care in south central Alaska, a fundamental shift occurred. Health care was now being provided in partnership with Alaska Native people by Alaska Native people. The system was rebuilt from a customer-driven perspective reflecting the principles and values of the Alaska Native people. The result was the SCF Nuka System of Care, which has resulted in most health outcomes now being in the top 25th percentile while showing markedly reduced use of hospital beds, the emergency department, specialists, pharmaceuticals, and clinical testing. In addition, our partnership with the community has led to SCF twice receiving the Malcolm Baldrige National Quality Award, which is the United States’ highest presidential honor for performance excellence.
Many of the practices of SCF’s Nuka System of Care align with the concept of equity-oriented health care (EOHC) as described by Ford-Gilboe and colleagues. They state that “fundamentally, EOHC is about creating safe and respectful environments while tailoring health care to fit the needs, priorities, history, and contexts of individual patients and populations served.” They identify 3 key dimensions of EOHC: trauma- and violence-informed care, culturally safe care, and contextually tailored care. SCF’s Nuka System of Care provides services that understand and address the impact of trauma and violence, build on culture and address historical inequities, and understand the unique story of each individual served and the context in which they are partnering around their health. However, there is a key element of SCF’s Nuka System of Care that has enabled all of these things and serves as a core element of the SCF system, without which we could not have made the impact we have: customer-ownership.
SCF does not use the term “patients” to refer to the people with whom we partner, as this term often carries a passive connotation and does not reflect the level of engagement for which we strive. Rather, since the Alaska Native and American Indian people we support are both our customers and the owners of the health care system—and of their own personal and family health journey—they are “customer-owners.” This is more than just a change in terminology; it reflects the idea that community and responsibility are woven together throughout the health care system and that community members are partnering together to improve overall health.
In any community, health care services will be more effective, respectful, and contextually appropriate if the workforce comes primarily from that same community and shares its history, context, and ways of relating. Health care provides value only if the individual and family do something different as a result of our interaction with them. Influence comes from trusting personal relationships. Trusting relationships are possible after all barriers have been removed: time, place, attitude, language, use of medical lingo, style, environment, and so on. Long-term trusting human relationships that are personal, connected in story, and always customer-driven and respectful are the core concepts of the SCF system. Now well more than half the members of SCF’s workforce are Alaska Native and/or American Indian people, including the entire board of directors, the president/CEO, 61% of the management/leadership, and all of the administrative support and front desk staff. EOHC is most effective when communities own and manage their own health care systems; after all, no one can better understand the challenges and inequities faced by a community than its members, the people who know its history and character—and all the little “games” that people use to avoid the difficult work of changing their own health habits.
The findings of Ford-Gilboe and colleagues’ research showing increased confidence in managing and preventing health problems in people receiving EOHC, as well as improved health outcomes for them, are strongly supported by our experience at SCF. As reported earlier, SCF has seen the number of customer-owners’ visits to the emergency department drop by 40%, and hospital stays, by 36%. Currently, 97% of customer-owners report being satisfied with the care provided by SCF; 96% that their culture and traditions are respected at SCF; and 97% that they have input into their care decisions. Most clinical outcomes are in the top 25th percentile nationally, and many are in the top 10th percentile.
The study by Ford-Gilboe and colleagues adds valuable information to the conversation about methods and strategies to affect health inequities. From the SCF experience, we would add that customer-ownership may be the most important point to consider in the discussion regarding EOHC. Changing the use of words, removing all dimensions of barriers to trusting personal relationships based in story, and intentionally and systematically reversing negative social norming all contribute significantly to this effort. Our experience has shown that when people are responsible for their own health care and the system is structurally and philosophically built to respond accordingly, the result is increased engagement, lower total cost, greater satisfaction, and better health outcomes for those for whom the system exists.
1. Ford-Gilboe M, Wathen CN, Varcoe C, et al. How equity-oriented health care affects health: key mechanisms and implications for primary health care practice and policy. Milbank Q. 2018 [published online ahead of print].
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Published in 2018
Marilyn Ford-Gilboe, C. Nadine Wathen, Colleen Varcoe, Carol Herbert, Beth E. Jackson, Josée G. Lavoie, Bernadette (Bernie) Pauly, Nancy A. Perrin, Victoria Smye, Bruce Wallace, Sabrina T. Wong, Annette J. Browne (for the EQUIP Research Program)
Significant attention has been directed toward addressing health inequities at the population health and health system levels, yet little progress has been made in identifying approaches to reduce health inequities through clinical care, particularly in a primary care context. In this study, researchers found that providing more equity-oriented health care in primary care settings—including trauma-informed, culturally safe, and contextually tailored care—predicts improved health outcomes over time for people living in marginalizing conditions. Read more