Southcentral Foundation (SCF) is an Alaska Native-owned non-profit health care organization in Anchorage, Alaska that is responsible for providing health care and related services to approximately 65,000 Alaska Native and American Indian people in Alaska. SCF took on this responsibility in 1998 and has continuously worked to improve its services ever since.

Many health care organizations spend hundreds of thousands of dollars on software to identify patients who are at risk and “forecast” utilization of health care services. Health organizations use this information for financial purposes and to identify “heavy users” of their system. Patients who are identified as “heavy users” are often assigned a special case manager or navigator, not for their benefit, but to reduce their number of visits and bring cost savings to the organization. However, the software often fails to accurately identify “heavy users,” and it also fails to provide information that will help providers meet the needs of the patient.

In contrast, SCF has created a disease agnostic system for identifying customer-owners whose behavior indicates that they have an issue impacting their health. When customer-owners have several admissions to the hospital or several visits to the ER, SCF does not scrutinize them, restrict visits, or change their provider or case manager. Instead, SCF’s staff looks for ways to partner with the customer-owner to help them reach their goals, and works together with the customer-owner to create a Wellness Care Plan to address the root issues they are facing (as defined by the customer-owner). SCF’s tracking system then reports the number of negative visits (ER, urgent care, etc.) and the number of positive visits (behaviorist, dietician, etc.) before and after the Wellness Care Plan. The goal is not to reduce the number of visits, but to work with the customer-owner to identify what changes can be made so that they are supported in a manner that works for them. The system allows SCF to evaluate, in real time, if the services provided are having an impact for those who need them most. It also provides data that SCF uses to improve population health.

This session will be valuable for anyone interested in finding an effective method for meeting the needs of the people using their health care system most. SCF’s data tracking tool and Wellness Care Plans are a person-centered method for ensuring that customer-owners receive the care they need and that the visits a customer-owner makes are effective at dealing with the health issues they face. The session will cover the specifics of SCF’s data tracking tool and Wellness Care Plans, as well as the general approach SCF takes with customer-owners and the best ways SCF has found to help them achieve wellness.

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