Among the pioneers of upstream care, a concern about unintended consequences has bubbled up lately. Many members of our community worry that addressing the social determinants of health puts us on a path towards the ‘medicalization of social services’, that is: reducing the social services and public health fields into a compartmentalized subsidiary of the healthcare delivery system. This concern came up at a recent event I attended and in recent articles, including this one by Lauren Taylor.
The concern is valid. I share it. But I believe we in the upstream care community are up to the challenge.
The conversations at the first ever Social Interventions Research & Evaluation Network (SIREN) conference in Portland were rich. Over 150 upstream researchers gathered to discuss the state of research in the social screening and referral world: How good is the evidence for the screening of certain health-related social needs (HRSNs) in healthcare settings? How can we generate better evidence for what works when and for whom?
Then I heard these reactions:
Wait…Is it our job in the medical sector to screen for HRSNs? If we identify these needs, does healthcare then have to address them all? Does that mean that healthcare systems will now be responsible for identifying and solving these needs, so that the main way to get a social need like food insecurity or housing met is to walk into a doctor’s office?
These questions point to a structural issue: Since we have long underinvested in social services relative to medical care, there is currently an imbalance of power between the two sectors. As efforts to integrate these sectors pick up, what’s to stop medical care from co-opting social services?
These questions and issues are honest, natural, and necessary. Indeed, it seemed almost cathartic for the group, getting all of our underlying anxieties out there. This is uncharted territory for many.
But, for those committed to upstream care, we can find our way forward by adhering to the following principles:
- Keep the patient and community at the center. We must ground ourselves in a patient & community-centered approach to care delivery and system design. This means giving those receiving care a seat at health care’s table. It means giving those with community expertise a seat at the table. This also means sometimes giving them your seat at the table. Or earning an invite to join their table. This includes asking them what they need to be healthy, what the community needs to be healthy. But above all this means listening with empathy, working with compassion, and acting in solidarity with that whole person – and our community – in mind.
- Clearly communicate objectives. Higher quality care? Lower total costs? Greater equity of outcomes across populations? As healthcare and social sector partners move upstream, we must all be precise in our language and clearly articulate the objectives behind our work. Effective communication ensures transparency, builds trust, and helps each part of the system better understand the role of the other.
- Find the leverage points for equity. We are not starting from nothing. There are particular aspects of upstream care that other sectors can use and build upon. For example, as health systems screen for social needs, how can this information help public health systems with HRSN surveillance and social epidemiology? How can advocates leverage this information to gain more real-time insights into what’s needed for policy change? As more healthcare professionals recognize their role in addressing upstream challenges, how can organizers mobilize them to support broader campaigns for justice and equity?
- Remember: Upstream care is better care. This is our guiding light. Indeed healthcare professionals like myself who have been on the front lines — who have cared for adults with HIV, for adolescents, for frail elderly patients, and for patients with complex mental health needs — have long known this to be true. Medical care should not co-opt social services; it should embrace and elevate social services. For the evidence from the frontlines is clear: When care is informed by social context, when health-related social needs are met, people live longer, better lives. Families and communities thrive.
There is a long history that got us to where we are today, and there are complexities and uncertainties in the path that lays before us.
But grounded by our truth and our principles, we can feel assured of our direction. We can be confident in our work.