Learning Circles and "story" have been used effectively in SCF’s Family Wellness Warrior Initiative for 15 years. Behavioral Health Redesign began with the vision of incorporating these traditional ways of teaching/learning into the behavioral health experience for our Alaska Native customer base. This change has improved our ability to build relationships and meet people where they are at in their journeys. Redesign has also introduced other changes to better match customer needs/values to resources/services. The old model was that when a customer called with a request for long-term, intensive therapy, we essentially had them “take a number” and wait for the first available clinician. The assumption was if they asked for it, that’s what they needed – but this could mean a month or more of waiting and was not always the best fit. Now, customers seeking services can walk into our outpatient programs and meet same-day, one-on-one with a master's level Behavioral Health Consultant, and a case manager if needed. BHCs can help determine the customer's motivation and readiness to change as they identify the customer's needs/challenges. Based on need and fit, the BHCs are making more referrals to Learning Circles and other SCF services than therapy intakes.
Redesign has created a comprehensive, culturally competent system design that is effective at a population-level scale. By offering upfront access to BHCs that listen and safely respond to personal narratives (vs. focused on intake paperwork) and multiple points of entry into services (e.g., Learning Circles that are offered to the public as “walk-ins” and some offered at churches/gathering places and correctional facilities), behavioral health is now more accessible and user-friendly. Co-location of psych/prescribers (MDs/ANPs) in primary care has also helped bring more mental health expertise into the setting where the majority of mental health presents. Those with complex needs can be referred to a new comprehensive case manager position for help with navigating functional daily living skills. The Learning Circles (with educational, therapeutic/clinical, and support goals) establish supportive relationships among small “communities” of customers, which is aligned with the cultural traditions and relational orientation of the Alaska Native people served.
Established in 1999, SCF's FWWI has long been using Learning Circles to create safe and supportive environments for customers to enter into their stories and begin a healing process. SCF first began integrating behavioral health into primary care in 2004. Redesign, rolled out in 2014, brought these two effective and award-winning approaches together for more impact. There are now more than 65 Learning Circle options and two dozen BHCs. BHCs are not only in primary care and pediatrics, but also, as part of Redesign, in behavioral health. SCF has become a “pilgrimage site” that draws other organizations/agencies interested in a practitioner’s approach to whole system transformation. “Sharing what we know” is an Alaska Native value. All the Redesign successes and lessons learned have been documented and are shared at conferences/trainings; for example, recently at the Collaborative Family Healthcare Association conference and every summer as part of SCF’s Annual Nuka Conference.
Redesign draws from years of experience addressing domestic violence/abuse/neglect through SCF's FWWI, including Learning Circle facilitation and providing a readily available one-on-one option. Within SCF's Nuka System of Care, known internationally for its customer-driven overhaul of health care delivery and sustained outcomes, infrastructure supports have been put into place to sustain innovation. For example, mandated trainings in improvement cycles and FWWI philosophy (relationship-building through story, etc.). While Redesign involves some non-billables, SCF has had success putting the customer first and investing upfront for downstream savings. Group-based Learning Circles are an efficient way to deliver services. Many are aligned to treatment plans and billable. Facilitator training is conducted quarterly by FWWI to foster a consistently positive experience. The co-located psychiatrists build capacity for primary care providers to deliver more mental health over time. When other service options can address behavioral health needs, missed/failed therapy appointments are eliminated, which improves access overall.
The desire for people (including customers of health care systems) to be “in relationship” is not unique to Alaska Native cultures. For target populations that share these values – and for organizations that are incorporating relationship building into what they do – SCF’s Redesign is a model for removing barriers to forming long-term, trusting, supportive relationships. SCF approached Redesign with a well-defined concept model diagram and a launch plan that was deployed over four phases. Elements were tested and piloted using the PDSA (Plan-Do-Study-Act) process with ongoing data tracking/analysis and check-ins. Staggered rollout in each of the clinics allowed organizational learning and ramping up to changes while still serving customers. Other (non-clinic) SCF behavioral health programs have also been involved with Redesign by identifying operational improvement opportunities (e.g., processes, staffing roles, flows, service options) that align with the goals of Redesign. All of the successes/lessons learned have been well documented.
Prior to Redesign, every customer seeking outpatient behavioral health services was required to have an intake. Half the customers would “drop out” during the average 42-day wait for intake, and then another 35% after intake. Because of Redesign, all customers can see a master's level BHC and a case manager, if needed, the same day they request services. BHCs are now partnering with customers to identify needs and recommend services: 35% of the customers seen have been referred to at least one Learning Circle and only 13% for individual, long-term therapy. Upon referral to therapy, the intake is scheduled an average of seven days out. Immediate access has also decreased the frequency of customers having a crisis situation develop that requires a “Code 99” response – down from two/week to seven in six months. SCF is also tracking satisfaction, days between appointments, DNKAs/failed appointments, # of encounters and referrals.