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"The Nuka System of Care leverages the assets within a community to drive better health care delivery."
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How to Build the Foundations for Community-Based Crisis Response

By Elias Miranda | Wednesday, April 21, 2021
How to Build the Foundations for Community Based Crisis Response

Photo by Stefano Ferrario | Pixabay

According to a Kaiser Family Foundation analysis, when ranked by share of state populations fully vaccinated against COVID-19, Alaska has consistently been at or near the top list. One of the state’s health systems reports that the foundation for this success has been built through more than 20 years of intentional relationship development with the people they serve.

Leaders from the Southcentral Foundation (SCF) recently spoke to members of the IHI Leadership Alliance and credited the strong partnership between Alaska Native communities and the tribal health system for their impressive COVID-19 vaccination rates. April Kyle, MBA, SCF’s Interim President and CEO, and Doug Eby, MD, MPH, Vice President of SCF’s Medical Services Division, described the Nuka System of Care that SCF practices as integral to this partnership.

Nuka, named for an Alaska Native word used for “strong, giant structures, and living things,” is a relationship-based, customer-owned approach to transforming health care, improving outcomes, and reducing costs. The Nuka System of Care challenges the typical health care hierarchy in which only the system is expert, and communication only flows downward to communities. It acknowledges that both the health system and communities bring knowledge and expertise.

Health councils are an important part of the Nuka System of Care. Health councils comprise family members from native communities who provide local governance for the health care that SCF delivers. Years of developing strong connections to the health councils set the stage for Alaska’s robust COVID-19 response. At the start of the pandemic, SCF’s leadership team spent hours talking with the health councils about the coronavirus and how best to approach protecting communities together. Listening to the voice of the community drove decision making and helped them address equity.

Health councils told SCF about the unique challenges COVID-19 would bring to their communities, including how to manage winter fishing, crabbing fleets, flight crews on small aircrafts, medical travel, and supply chains for groceries and other supplies in often remote villages with concentrated housing densities. As a result, communities were able to set their own travel guidelines and quarantine requirements, and SCF had regular dialogues with councils to reevaluate plans as the knowledge and impact of the virus evolved. Developing trust and co-creating a response throughout the early stages of the pandemic paid off when it came time to plan for vaccine distribution.

Discussions about vaccines started last summer, and the conversations became more frequent as news about promising vaccine development spread. As vaccine rollout began, SCF integrated care teams called every SCF patient as soon as they became eligible to ask if they wanted the vaccine. Patients who were hesitant or had questions about vaccines had the opportunity to speak directly with their primary care provider to talk through their concerns. As vaccine eligibility requirements evolved, SCF talked with community and tribal leaders to ask who should be prioritized to best meet the needs of their communities. Investing time and resources in personalized conversations and responding to the particular needs of each community were instrumental in producing a high vaccination rate.

The Nuka System of Care leverages the assets within a community to drive better health care delivery. Consequently, as more vaccines became available, SCF decided to use the influence of the early adopters. Before the rest of the state, SCF made shots available to people 16+ so those already immunized could help explain the process and safety of getting vaccinated to their communities.

Based on their experience before and during the pandemic, Kyle and Eby offered some advice for health systems interested in how to co-produce better health and health care with their communities:

  • Approach communities with a collaborative mindset. Both health systems and communities bring their own knowledge, resources, and expertise. It is vital to engage with them as equal partners to find the best ways to leverage those assets to benefit the health of everyone in the community. It is essential to be close to your community and to listen carefully to their voice.
  • Take a long-term approach to community building. The success of SCF’s COVID-19 response and vaccine rollout did not happen overnight. It is the result of investing decades of time and resources. To reach the stage where health systems and communities are co-designing care, health systems must listen to the needs of communities and develop relationships and trust over time.
  • Determine the community orientation of your health system. Health care leaders are given immense power over resources, and it is essential that they use these resources to follow the directions given by communities. They should create environments that empower communities, and use existing systems and strengths whenever possible. As SCF’s story illustrates, co-designing solutions with (and not just for) communities drives change that promotes health and wellness.

Both Eby and Kyle expressed profound appreciation for their staff who have been on the ground working with patients for decades. They noted that making the most of the staff’s talents and recognizing them when they go the extra mile for patients help incentivize them to prioritize relationship building. These and other long-term efforts have helped SCF face the current crisis and offer examples of how to partner with communities, redesign care, and move forward after the pandemic.

Elias Miranda is an IHI Associate Project Manager.

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