Headline

Toolkit can help guide implementation of integrated care teams into primary care settings.

Context

Long-term relationships between a provider and patient are a key element of primary care, but are too often constrained by inadequate staffing, high caseloads, long wait times for appointments, etc. This toolkit is produced by Southcentral Foundation’s Nuka System of Care, an integrated care delivery system serving Alaska Native and American Indian people in Anchorage and rural villages. Southcentral’s Nuka System has transformed its primary care and other programs by listening to their local community and committing to delivering a high level of relationship-based care.

About this Tool

The toolkit lays out steps and worksheets to help successfully implement integrated primary care teams, grounded in examples from Southcentral’s project plans. The content outlines steps for developing a vision, mission, and project charter, as well as developing and implementing action plans, including planning for:

• Team composition and roles and workload balance;
• Empanelment, panel management, and specialty referrals;
• Access across the system’s patient population;
• Operational considerations, including facility space considerations:
• Communication and employee recognition; and
• Data and training supports.

Takeaways

Health care leaders, clinicians and administrators can use this toolkit to learn practical strategies for developing integrated primary care teams to improve relationship-based care. The steps are meant to be adaptable, depending on the unique needs of different health care organizations.