Southcentral Foundation Elder Program: Alaska Native Elder Care Services

If your parent is an Alaska Native or American Indian elder in the Anchorage or Mat-Su area, Southcentral Foundation (SCF) provides a care coordination model that works differently from the standard Medicare/Medicaid system. Understanding what SCF offers — and how it integrates with hospital discharge planning — can significantly change how your family navigates a post-hospital transition.

The CHOICE Model

Southcentral Foundation operates under the CHOICE (Customer-Owned and Healthy Integrated Care Environment) model, a nationally recognized integrated primary care system. The key difference from conventional healthcare: every customer-owner (SCF's term for patients) is assigned an integrated care team that includes a primary care provider, nurse, certified medical assistant, and behavioral health consultant.

For elder care, this team-based approach means the primary care provider already knows your parent's medical history, current medications, and social situation. When a hospital discharge happens, the SCF care team is positioned to coordinate the transition rather than relying on the hospital's discharge planner to cold-call a primary care office.

Elder-Specific Services

SCF provides several elder-focused services through its primary care and behavioral health divisions:

Care coordination. For elders with complex medical needs — multiple chronic conditions, recent hospitalization, cognitive decline — the care team coordinates across specialties, manages medication lists, and schedules follow-up appointments. This coordination role is especially valuable during hospital-to-home transitions, when medication changes and therapy schedules need to be reconciled with the existing care plan.

Home-based services. SCF coordinates with home health agencies and personal care providers to arrange in-home support for customer-owners. For elders returning home after hospitalization, the care team can initiate home health referrals, assess home safety, and connect families with community resources.

Behavioral health integration. Depression, anxiety, and adjustment disorders are common in elderly patients after hospitalization — especially those facing a sudden loss of independence. SCF embeds behavioral health consultants directly into the primary care team, so mental health support doesn't require a separate referral and a separate appointment.

Family engagement. SCF's model explicitly involves family members in care planning. If you're the adult child managing your parent's care, the SCF team can include you in appointments, care plan discussions, and discharge coordination calls.

How SCF Coordinates with Hospital Discharge

When an SCF customer-owner is admitted to Alaska Native Medical Center (ANMC) — which is co-managed by the Alaska Native Tribal Health Consortium (ANTHC) and SCF — the discharge planning process can tap into SCF's integrated system.

What this looks like in practice:

• The hospital discharge team can access the patient's SCF care team directly, sharing discharge summaries and medication changes in near-real-time
• Follow-up appointments with the SCF primary care provider can be scheduled before the patient leaves the hospital
• The care team can arrange home health, physical therapy, and personal care referrals within the tribal health network
• For patients returning to villages served by SCF's network, regional liaisons coordinate travel, medication availability, and local clinic follow-up

If your parent was admitted to a non-ANMC hospital (Providence, Alaska Regional, a military facility), the SCF care team may not receive automatic notification. In that case, call SCF's scheduling line to inform the care team about the admission and request discharge coordination support.

Eligibility

Southcentral Foundation serves Alaska Native and American Indian people who live in the Anchorage Service Unit area, which covers the Municipality of Anchorage and the Matanuska-Susitna Borough. Customer-owners who have moved to the area from other tribal health regions can transfer their care to SCF.

Eligibility is based on tribal enrollment or descendancy — not on Medicaid, Medicare, or income status. SCF provides care regardless of insurance coverage, though it bills Medicare, Medicaid, and private insurance when applicable.

For elders in other regions of Alaska, the corresponding tribal health corporation provides similar (though not identical) services: YKHC in the Yukon-Kuskokwim Delta, SEARHC in Southeast Alaska, Tanana Chiefs Conference in the Interior, and Bristol Bay Area Health Corporation in Bristol Bay.

Connecting With SCF

• Primary care scheduling: 907-729-3300
• Location: 4501 Diplomacy Drive, Anchorage, AK 99508
• After-hours nurse advice line: Available 24/7 for customer-owners

For the complete framework covering tribal health coordination, Medicaid waiver navigation, and hospital discharge planning across Alaska, see our Alaska Hospital Discharge Toolkit.

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