Charting a Course for Social Determinants of Health

By Rishi Manchanda, MD MPH, President, HealthBegins


Healthcare systems are talking about moving upstream. The Upstream Strategy Compass can help them get there.


Cross-published with the Practical Playbook blog


When Kaiser Permanente recently announced that it will invest $200 million to prevent homelessness and ensure healthier homes, the healthcare world took notice. The size of the investment was notable, but what makes this truly newsworthy is that it represents a bellwether for changes that the rest of healthcare is just beginning to experience.


Moving upstream to improve health is not only necessary — as Kaiser made clear in its announcement — it is also possible. The question now facing many healthcare systems is this: We know we need to move upstream like Kaiser, but how do we get there?


To help answer that question, my colleagues at HealthBegins and I developed the Upstream Strategy Compass(TM), a tool that can help healthcare and community partners chart a course together.


​Population health[1] (i.e. efforts to improve health, wellbeing, and equity for defined populations and/or communities) is increasingly a core part of the mission of hospitals and clinics, as medicine moves toward value-based care. As a result, hospitals and clinics — and payers — are showing greater interest in “upstream” social determinants of health and how to improve value and population health outcomes by addressing them.


For instance, more and more hospital community benefits departments are moving from simply “checking the box” with obligatory community health needs assessments (CHNAs) toward a more proactive and strategic approach to building a portfolio of health investments in their surrounding communities. At the same time, healthcare delivery systems are building and refining care models to better screen and address health-related social needs for patients. From strategic community investments to screening patients, these efforts to address social determinants will be key to the modern mission of hospitals and clinics.


Pursuing a mission in which population health is front and center presents major challenges to healthcare systems. First, identifying and implementing clear population health priorities across diverse clinical and community stakeholders is still a complex challenge. Second, as healthcare systems assess their organizational capabilities to address social determinants, they must grapple with scope. For many healthcare systems, issues like food insecurity, homelessness, and structural racism can feel overwhelming and beyond the scope or reach of conventional clinical practice.


To address these challenges, healthcare systems can use a taxonomy of clinical-community partnerships to, first, categorize unmet social needs for priority populations and, second, identify opportunities to intervene on seemingly intractable social determinants of health in concrete, actionable ways. The Upstream Strategy Compass(TM), for example, uses levels of prevention (i.e. primary, secondary, and tertiary) and levels of intervention (i.e. individual, organizational, community) to help healthcare systems and their community partners understand local needs as well as the opportunities to improve specific social determinants of health for priority patient populations.[2]​


The Upstream Strategy Compass(TM) chart

Figure 1. Upstream Strategy CompassTM. Manchanda R. Copyright HealthBegins 2018. Reproduced with permission. Abbreviations: DM, diabetes mellitus. DPP, Diabetes Prevention Program. Grey boxes represent “early wins.” [3]


Figure 1 provides an illustrative example of how healthcare and community partners can map potential solutions to address and/or prevent food insecurity for a priority population of adult diabetics across different levels of intervention and prevention. Using this strategic framework, hospitals and community partners can then use an impact/feasibility analysis to select “early wins” to help them move upstream collaboratively (see “early wins” represented by the gray boxes in Figure 1).


​The Hospital Association of Southern California (HASC), for example, is using the Upstream Strategy Compass(TM) to help member hospitals identify population-health early wins to improve diabetes and the social determinants of diabetes within their regions. As HASC is demonstrating, healthcare systems can use this framework to circumscribe their roles, i.e. where healthcare can lead, partner, and/or support, to achieve early wins through clinical-community partnerships. Similarly, community partners such as food banks or public health departments can identify where they can lead, partner, and/or support early wins.

In our experience, the majority of healthcare institutions that are currently working on social determinants of health are engaged in activities that fall in the bottom left of the Upstream Strategy CompassTM. In other words, most of today’s “upstream” work in health care consists of individual-focused, tertiary prevention activities designed to mitigate and reduce the impact of disease and preventable utilization among high-need, high-cost patients. Healthcare hotspotting is an example of this type of tertiary-prevention activity.[4]


For hospitals and clinics, however, long-term success in population health will depend on our collective ability to diversify and balance our portfolio of community health investments with strategies that are out of the box, so to speak, beyond tertiary-prevention, individual-level efforts.


The Upstream Strategy Compass(TM) and other emerging strategic and operational frameworks can help healthcare and community partners to chart a course to move upstream together. Instead of wondering how to move upstream, these tools will enable us to ask a different question: How quickly can we get there?


This blog is adapted from a chapter written by Dr. Manchanda for the second edition of the Practical Playbook, which is due to be released in the summer of 2018. 


[1] Pathways to Population Health: An invitation to health care agents. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2018. (Available at

[2]  Manchanda R. Practice and power: community health workers and the promise of moving health care upstream. J Ambul Care Manage. 2015;38(3):219–24

[3] Manchanda R. The Upstream Strategy CompassTM. HealthBegins. Los Angeles, CA. 2018.

[4] Healthcare Hotspotting: A project of the Camden Coalition of Healthcare Providers  Accessed April 18, 2018.



Featured Content

Staff Spotlight: Erica Jones, Following Her Path and Passion to Help People

“I wish people would try to advocate for themselves more, because I feel like there's this power struggle and people don't feel like they can.”

Staff Spotlight: Kyron Pierce, The Eagle Scout with a Passion For Helping People Lead Healthy Lives

“[Health equity] is very hard work and it might be some years for us to see the fruits of our labor, but it'll be worth it when you do produce it.”

Staff Spotlight: Alejandra Cabrera, Perfectly Imperfect Artist and Health Equity Advocate

When I work with people and communities, I always think back to this sense of not belonging and it drives me to continue to do the heart-work we need to do to advance health equity.