Alaska, United States: Service Quality


The Southcentral Foundation’s (SCF) Nuka System of Care has served a population of approximately 60,000 mostly low-income and marginalized American Indian and Alaska Native individuals residing in Anchorage, the Mananuska-Susitna Borough, and 55 rural villages comprising the Aleutian Chain and Pribilof Islands. SCF assumed full responsibility for this population in 1999. Previously, the area was served by the Indian Health Service and operated inefficiently. Patients often experienced long wait times, limited access to primary care, and felt little control over their health system.1 Additionally, patient care lacked both continuity and coordination; patients often visited different physicians and sought care in multiple places.

How facility organization and management was integrated into reforms

The establishment of Southcentral Foundation’s Nuka System of Care was catalyzed by United States legislation that facilitated tribal ownership of services. With this shift came a complete restructuring of services; many of these reforms involved facility organization and management. Multidisciplinary teams were established with a specified panel of approximately 1,500 customer-owners. Teams include a primary care physician, nurse case managers, certified medical assistants, and administrative staff.2 In 2004 a new cadre of providers, behavioral health consultants, were integrated into practices in reaction to the high volume of visits concerning alcoholism, intimate partner violence, depression, and other behavioral health concerns.2 The shift to team-based practice was facilitated by facility leaders who set goals and aimed to cultivate a culture of flexibility and teamwork. Additionally, facility leaders developed a mission statement and key points to guide communication and decision-making. Facility management was also led by customer-owners who comprise the entirety of the governing board.3 The Southcentral Foundation created an information system called the Data Mall to monitor performance against various benchmarks including internal and external clinical and performance measures. The indicators used for performance measurement were selected based on their relevance to the Southcentral Foundation’s mission and key points, thus ensuring that communication of performance can address the goals of the organization.1

Outcomes & Impact

The Southcentral Foundation has experienced tremendous growth as a result of the reforms, now serving more than 60,000 individuals and comprising 1,500 employees. More than 95% of the population is empaneled to a care team, facilitating continuity and comprehensiveness. Waiting times have been significantly reduced and same day appointments are available either in person or by phone.1 In 2009, the Nuka System of Care was recognized for having achieved the highest level of the Patient Centered Medical Home standards. Implementation of the Nuka System of Care has resulted in numerous health improvements among customer-owners.  Inpatient hospitalizations for any reason and hospitalizations for unintentional injury or poisoning declined during and after implementation.4 Additionally, customer-owners now feel greater agency and input in the design and functioning of their health system.3

Suggested citation: “Facility Organization and Management: Alaska, United States.” Improvement Strategies. Primary Health Care Performance Initiative, 2018, Accessed [insert date].


  1. Gottlieb K. The Nuka System of Care: Improving health through ownership and relationships. Int J Circumpolar Health. 2013;72(SUPPL.1):1–6.
  2. Sullivan E, Hufstader T, Arabadjis S. Behavioral Health and Financing for Southcentral Foundation’s Nuka System of Care ( B ). 2015.
  3. Gottlieb K. The Nuka System of Care: Improving health through ownership and relationships. Int J Circumpolar Health. 2013;72:1–6.
  4. Johnston JM, Smith JJ, Hiratsuka VY, Dillard DA, Szafran QN, Driscoll DL. Tribal implementation of a patient centred medical home model in Alaska accompanied by decreased hospital use. Int J Circumpolar Health. 2013;72(SUPPL.1):1–7.