Southcentral Foundation’s Playbooks

Southcentral Foundation was one of the first organizations to implement integrated primary care (also known as team-based or multidisciplinary care), pioneering its Integrated Care Teams (ICTs) as part of the rollout of the relationship-based Nuka System of Care in the late 1990s.

Now, in order to support sustainability of our own transformation, as well as to help other health care organizations implement and improve integrated care teams, SCF has created the Integrated Care Teams Playbook and the Behavioral Health Integration Playbook, which are based on SCF’s experiences and lessons learned in implementing these systems. The playbooks are organized using SCF’s READI model, which SCF uses in other areas, including improvement and innovation, and consulting with outside organizations.

Integrated Care Teams Playbook

Southcentral Foundation’s Integrated Care Teams Playbook includes information about all aspects of implementing and sustaining integrated care teams, including but not limited to team composition, roles and responsibilities of each member, improving access for customer-owners, workload balance, empanelment, facility considerations, data considerations, improvement and innovation, and more. This information comes from SCF subject matter experts who have been with SCF since before ICTs were established and were key figures in SCF’s system transformation. The playbook also includes tools SCF still uses in operating its ICTs today.

Integrated Care Teams Playbook: Supplement on Empanelment

As discussed in the Integrated Care Teams Playbook, empanelment is the pairing of customer- owners and Integrated Care Teams. SCF does not assign customer-owners to care teams (except in the case of newborns; more information on this is included in the newborn empanelment section), but rather allows them to choose their care teams. This supports the building of relationships between customer-owners and their care team. If possible, all customer-owners your organization serves should be empaneled to a care team, and should always be seen by that care team and work with that team on their health goals and needs.

This supplement contains additional information related to empanelment.

Behavioral Health Integration Playbook

Southcentral Foundation’s Behavioral Integration Playbook includes information about how to set up systems for integrated behavioral health in a health care organization. The playbook discusses many aspects of integration, including but not limited to roles and responsibilities of integrated behavioral health consultants, approaches to clinical behavioral work, workload balance, facility considerations, data usage, charting, how to ensure access to behavioral services, and more. The information in the playbook comes from SCF subject matter experts who were part of SCF’s original implementation of integrated behavioral services.

Are you READI?

Implementing changes can be difficult, especially at larger organizations, and these changes can sometimes face institutional resistance. Southcentral Foundation has a great deal of experience with organizational change, having transformed our health care system to better serve customer-owners, and continues to implement organizational changes and improvements today as they are needed. To help with this process, SCF has developed the READI approach.


First, we reach an understanding about what solutions could positively impact your organization.


Second, we establish relationships, navigating team dynamics and their impacts to moving projects forward. We have communication and project management tools to help navigate your organization through change.


Third, we do an assessment of gaps and possibilities. We’ll transform data into information, and compare current state to future state to identify gaps and possibilities.


Fourth, we’ll develop and implement an action plan. We’ll design an action plan that includes measurable results, then ensure we have buy-in from your teams and leadership.


Finally, with Nuka experts and our quality improvement toolbox, we’ll walk side-by-side with you to implement solutions at your organization.

Contact Us

Southcentral Foundation’s team of subject matter experts are available to assist your organization in implementing integrated care teams and behavioral health integration at any phase of readiness. Contact us today for your 1-hour complimentary assessment.

Call us today!

(907) 729-NUKA (6852)