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Nuka System of Care

Transformative Partnerships

Case Study: Nuka System of Care

Improving Health through Ownership and Relationships

Southcentral Foundation’s Nuka System of Care is built around the understanding that personal, long-term, accountable relationships with customer-owners, their families, and their communities are the key to making a difference in the ongoing choices and habits that drive health and wellness.

For 50 years, Alaska Native people in Southcentral Alaska received their health care as “patients” of the Indian Health Service’s Native hospital. Patients had to wait weeks to get an appointment, and saw different providers each time. Treatment was inconsistent, care was impersonal, and there was a disconnect between care for the mind and care for the body. Departments and programs acted independently. Patients weren’t happy, employees weren’t happy. Health statistics were bleak. Many patients left the Alaska Native system altogether to find better care. Then, Congress passed a federal law in favor of self-determination. This gave Alaska Native people a voice in the planning and implementation of programs to respond to the true needs of their communities. It also opened the door for tribes to eventually own the entities that deliver the services. The Alaska Native leadership of Southcentral Foundation (SCF) saw this new law as an opportunity for innovation – to completely redesign the tribal health care system in Southcentral Alaska with a primary focus on relationships.

By 1999, Alaska Native people were no longer “patients” of a government-run system, but, rather, chose to become “customers” and “owners” of their tribally managed health care. What followed was a customer-driven overhaul of health care delivery, philosophy and values. As a result, SCF has today what is known as its “Nuka System of Care.” It addresses the challenges that health care systems around the world face – how to improve health care outcomes and customer satisfaction without skyrocketing costs. It works because SCF redesigned the entire health care system based on the wants and wishes of its customer-owners (who asked for the emphasis on relationships), and, in doing so, empowered those receiving the services to share responsibility.

Finding the correct diagnosis and creating the best treatments are secondary to the real work of partnering, encouraging and supporting in personal relationships over time.

Once under Alaska Native customer ownership, SCF recognized the need to introduce Alaska Native managers into the system. Not only did this build highly capable Alaska Native leadership for the future, but it also allowed the doctors and nurses who had previously been serving as the department managers to return to predominantly clinical work. Today, over 60% of the organization’s managers are also customer-owners. In their management roles, again, the emphasis is on relationships – both with co-workers and fellow customer-owners. Grace Hamner is a good example. She has served as the Optometry Clinic’s manager for over 10 years. She’s been a part of customers’ lives from adolescence through adulthood. She also gets to know her employees and the areas they want to grow into, so that she can match them with related learning opportunities. Her strong relationships with the other managers make it easy to ask questions, learn what works well in their settings, and then modify it for her setting. She says, “As Alaska Native people providing services for our own families, we know the importance of looking at the needs, forecasting, and determining what direction we need to go next.”

The Nuka System of Care is a departure from “patients” serving as mere recipients of tests, diagnoses, and pills. Instead, customer-owners actively share responsibility for the success of the health care system and for their family’s health and wellness.

Shared Responsibilty


  • Listen
  • Provide choices
  • Keep Commitments


  • Communicate goals
  • Engage in decision making
  • Keep commitments

Before the Nuka System of Care, far too many Alaska Native people believed that they had no control or opportunity for input. This belief was conditioned over many decades of well-intended with government-run health care that promoted the message “we will take care of you.” While the system is far from perfect, there have been measurable improvements. For example, a recent yearlong survey asking customer-owners about their experiences in SCF’s clinics showed that 98.5% of the respondents agreed with the following statement: “I was given the chance to provide input into decisions about my health care.”

Other Results:

  • In 1996, only 35% of the local Alaska Native population had a designated primary care provider. Of those, 43% did not know who that provider was. Now, over 95% are empanelled to an integrated primary care team. Providers know their customers’ names, as well as their histories, preferences, and family dynamics.
  • Before Nuka, the average delay to schedule a routine appointment was four weeks. Now, Southcentral Foundation offers same-day access, in person or by phone or email (customer’s choice).
  • Phone wait times, before Nuka, were in excess of two minutes, and are now limited to less than 30 seconds.
  • A 36% reduction in hospital days, 42% reduction in ER and urgent care usage, and 58% reduction in specialty clinic visits have been sustained for 10+ years.
  • Staff turnover is one-fourth of the level it was five years earlier.
  • Customer satisfaction with respect for their cultures and traditions is at 94%.

SCF’s customer-owners recognize that their families will own, manage and benefit from these services for generations to come. With this ownership, comes a sense of shared responsibility for the health care system’s success. The people of the region are working to continuously improve the services and ensure that the decisions made are in alignment with a set of relationship-based operational principles. By being involved, Alaska Native people are now more aware of health promotion and disease prevention options and are more interested and willing to make changes.

The value put on relationships in this Alaska Native-owned system of care provides a dramatically different care experience than what was encountered when the health system was under government control. Better relationships have meant not only healthier customer-owners, but also healthier employees and a healthier organization.