This is the second part in a series reviewing HealthBegins’ innovative tools for health equity strategic planning and portfolio development. See Part I here.
The pandemic and lockdown taught us all viscerally that the level of connection and trust we build with other people matters deeply for our mental and physical health. The deeper our bonds go, the more we look out for one another and take steps to make the lives of those around us better. But it turns out that the density and quality of relationships between the institutions in our communities—such as schools, clinics, libraries, and government agencies—matter for our health too.
And in some cases, the strength of those networks can be life-saving. This concept is known as “community social capital” or “comprehensive system capital.”
As health care ramps up equity efforts, we must invest in building this type of community or system capital. While we focus on closing care gaps and meeting new short-term performance requirements, we have to make sure that our institutions, and the ecosystems they belong to, are aligned to promote health equity and healing rather than inadvertently perpetuating structural violence and inequities. To do this, we need to organize a dizzying patchwork of clinical and community programs—patient safety, health equity, social needs, quality improvement, DEI, community benefit, and impact investments—into a cohesive portfolio.
How do we do this? We start by committing ourselves and our institutions to drive and support equity-focused improvement and transformation across multiple levels of intervention. That certainly means equitable delivery and access to care, but it also means looking beyond the clinics, offices, and business units that usually define the scope of our work and applying our efforts more broadly—from transforming patient care and institutional policy, to helping to reshape community conditions and the societal practices that put people in harm’s way.
To help institutional leaders pursue this North Star, we created the Compass for Health Equity Transformation (“Equity Compass”), which leaders in nonprofit health systems, managed care plans, and federal agencies use to define their health equity goals and chart their path forward. This practical translation of the social ecologic model helps leaders set their sights beyond mere compliance with statutory requirements towards real impact.
The Equity Compass, however, is only a first step. As institutional leaders use it to consider and develop multi-level health equity strategies, their curiosity grows and their imagination expands. They wonder how they can do more to prevent further inequities, heal and strengthen the communities they serve, and repair and grow relationships to collectively advance equity. To answer these questions, health equity leaders and teams need a way to look at inequities through a community, place-based lens and to re-imagine how and where they will allocate their resources and equity investments over time, including strategies to address social and structural drivers of health inequity.
Instead of juggling a seemingly disparate patchwork of health equity programs and pilots, they need to develop a more cohesive portfolio approach to their health equity investments—one that spans levels of prevention and not just levels of intervention. That’s what another HealthBegins tool, the Upstream Strategy Map for Health Equity Transformation (“Upstream Strategy Map™”), has helped healthcare organizations and partners do since 2015. (Click through the interactive graphic below to see the Upstream Strategy Map in action.) The Upstream Strategy Map is a strategic framework that maps opportunities to advance health equity across four levels of prevention (health promotion, primary and secondary prevention, and treatment) and four levels of intervention (care delivery, institutional, ecosystem, and societal).
This tool expands on the foundational capabilities of the Equity Compass, offering deeper strategic planning and comprehensive portfolio management across both prevention and intervention levels. In short, the Equity Compass helps leaders set a destination for their strategic portfolio, while the Upstream Strategy Map charts a course to get there.
How Leaders Are Using the Map to Drive Change
The tool has been used by leaders in many settings – large nonprofit health systems, Medicaid health plans, statewide coalitions, regional hospital associations, multisector place-based collaboratives, federal agencies, and health funders – to bring about transformation in three steps:
- Assessment. Current investments in healthcare equity are driven by expanding regulatory policy and accreditation standards. While new, welcome requirements from Medicaid, The Joint Commission, the NCQA, and other bodies can have positive effects like making healthcare institutions accountable for equity and social drivers of health equity, they can also have unintended negative consequences. They might lead some people working in health care to think with a compliance mindset, rather than one focused on long-term impact. What a portfolio approach and the Upstream Strategy Map help healthcare organizations do is zoom out, think about all of their investments, and assess them in new ways.
For example, with support from HealthBegins, leaders in HRSA’s Maternal and Child Health Bureau (MCHB) recently participated in an exercise to assess opportunities to better address upstream drivers of health outcomes. The MCHB reaches more than 61 million pregnant people, infants, and children, including children with special healthcare needs. Using this tool, leaders from MCHB divisions and offices learned to assess and categorize their programs across levels of prevention and intervention—from treatment and secondary prevention efforts that support hospital-based efforts to improve perinatal care to population-wide health promotion strategies that support maternal and infant health. In the process, they expanded their strategic vision and are now discussing opportunities to fill gaps and help grantees move upstream to drive equity-focused impact across a broader continuum of prevention and intervention.
Over the years, leaders have expressed appreciation for the ways the Upstream Strategy Map helps challenge norms in health care that focus organizational thinking and planning solely on individual-level services for patients or clients with complex diseases or severe social challenges. Instead, leaders attest that this tool helps challenge healthcare teams to think more “upstream” and assess their role in advancing health opportunities along the continuum of prevention. For vanguard systems, the Upstream Strategy Map helps health care teams ensure that they are focused not only on compliance, but on achieving long-term impact. - Portfolio planning. When healthcare organizations uncover a pattern of inequity in a specific health condition impacting a specific population (e.g., inequities in diabetes outcomes that adversely impact racially minoritized patients in specific neighborhoods), many struggle to align a disjointed patchwork of programs and pilots to address this problem. And some leaders wonder how to balance the need to close the gap between subpopulations with the desire to address the injustices that created the gap in the first place. Instead of a patchwork, health systems need a more cohesive, place-based portfolio of investments, one focused on eliminating specific healthcare inequities and addressing the social and structural drivers of those inequities from a health justice perspective.
This is one of the strongest benefits of the Upstream Strategy Map.
Healthcare leaders and teams learn to use the Upstream Strategy Map taxonomy first to categorize existing investments that can advance health equity, and second to identify untapped opportunities to intervene in concrete, actionable ways. Lastly, healthcare leaders work with community partners to design a balanced, data-driven portfolio that includes health equity interventions across the continuum, from helping individuals in crisis to population-level prevention measures and policy reforms.
For example, health equity leaders at Corewell Health, Michigan’s largest nonprofit healthcare system, have used the Upstream Strategy Map to engage regional leaders in mapping current clinical and community benefits programs that seek to increase maternal health equity across levels of prevention and intervention. They’ve used it to identify ways to enhance and complement vital acute-care services (i.e., tertiary prevention program-level strategies) by increasing investments in primary prevention and in ecosystem-level and societal strategies to address structural drivers of maternal health inequities.In the process of using this tool, healthcare teams move past overly simplistic and limiting questions about their role in addressing health equity and social needs (“Is this healthcare’s job or not? Is this our lane or not?”). Instead, the Upstream Strategy Map helps healthcare teams and community partners define where they can each lead, partner, or offer support in a comprehensive portfolio. - Defining and tracking value and impact. With goals and a strategic portfolio in place, the question becomes how to prioritize and track health equity investments over time. Critically, different methodologies are needed to define potential returns, value, and impact at each level of transformation.
For example, estimating traditional return on investment (ROI) can help convince chief financial officers to invest in health equity and social needs efforts that can change healthcare utilization costs or unlock short-term savings and revenue from value-based payment models (see HealthBegins’ ROI calculator). And since these investments can bring a range of other non-financial benefits for institutions, it is also essential to use value on investment (VOI) methods and tools to estimate the potential value of these interventions, especially those that will take time to show benefits. (Stay tuned for more about HealthBegins tools to estimate ROI and VOI, as well as lessons from HealthBegins’ VOI Accelerator, a program which just helped a cohort of community-based organizations across the country use VOI methods to advance clinical-community partnerships to address social needs.
Finally, for health plan community reinvestment projects or hospital community benefits efforts that seek to drive local ecosystem-level change, social return on investment (SROI) methods are often better suited to estimate and track impact. In our experience, healthcare leaders that use the Upstream Strategy Map to assess and develop more cohesive portfolios are well positioned to apply ROI, VOI, and SROI methods to measure, track, and message the return, value, and impact of their portfolios.
Taking this portfolio approach to investing in health equity isn’t just about looking more broadly at specific inequities; it’s about applying a health justice approach and creating cultural shifts in the way health care identifies, thinks about, and responds to them. Instead of simply describing gaps in outcomes, this multi-level approach helps us intervene on the injustices that create the gaps. It shifts the center of gravity away from the four walls of a hospital toward the community, centers community needs while balancing the needs of institutions, and prioritizes equitable long-term outcomes over short-term process measures.
Critically, it also helps healthcare institutions think about where to lead and where to step back and support community partners in their efforts. Using the Upstream Strategy Map, healthcare leaders set their sights beyond compliance and make investments that equitably re-allocate power and resources to improve health for all. This is the way to ensure healthcare institutions aren’t perpetuating harm and instead are true partners for health equity.
Contact us to learn how to use the Upstream Strategy Map: