From Transactional to Transformational: The Next Level of Upstream Care

By Rishi Manchanda MD MPH, President & CEO, HealthBegins

​To understand our next mission in upstream medicine, consider this classic proverb:
Give a man a fish and you feed him for a day; teach him to fish and you feed him for a lifetime
​The Upstreamist in me sees that sensible idea and says: “Yes, that’s good. But what if he can’t attend or afford the lesson? What if the pond is polluted? What if he or she has no fishing rod or needs to present a fishing license that only privileged people can acquire? Why not teach a woman to fish?”

It’s a mischievous little twist on the metaphor, but it gets at something really meaningful: the fact that meeting patients’ health and social needs is only the beginning of our work. To truly promote health for all people and communities, we must also think and act bigger.


​Here’s what I mean:
  • Our early work as Upstreamists has focused on improving the transactional dimensions of care — i.e. identifying that our patient is hungry, lonely, or homeless; identifying a community partner who can address that need; and establishing workflows to connect the patient with the partner. These days I meet more and more executives, vendors, and even investors with newfound interest in health-related social needs, with a desire to derive financial ROI from improving the transactional relationships between healthcare and social service providers. It’s why we developed a social-needs integration framework and help partners define a business case for their upstream care. This is crucial work, and we’re getting better at it all the time. But it can only get us so far.
  • Good upstream care is relational. At HealthBegins, we work with our partners to improve the human relationships that are at the heart of good health and social care: between caregivers and patients, between healthcare and social service professionals, and among advocates and leaders from all health-related sectors. We know that upstream care, like all strong relationships, moves at the speed of trust. So we released the Upstream Communication Toolkit to support these relationships. In our work, we also demonstrate how upstream care can foster joy at work among clinicians and care teams. My colleagues and I recognize that this is part of the magic of moving upstream: it builds stronger connections among all involved. It makes care better. In describing our work, Paul Farmer put it best:​
“A better understanding of efficiency, effectiveness, and value in health care is not the only reason to adopt upstreamist approaches… . Understanding more about the causes of the causes will help make medicine matter, help make it better, in part because it forces us to be better listeners.”
  • At its best, upstream work is transformational. Even the smoothest, most value-based transactions between healthcare and social services, delivered through respectful and trusting relationships, still take place in an unequal system where the communities in which patients and caregivers live and work are shaped by unjust structures and unhealthy policies — what the World Health Organization calls the “the causes of the causes.”  Transforming unjust systems and unhealthy policies is what we and our partners in upstream care must tackle now. In fact, we’ve already started.


For example, one of our large health-system partners began its journey upstream by screening patients for food insecurity and improving the ways in which food resources are provided (transactional and relational). Now, we’re helping this system explore how to use its institutional and investment power to ensure that healthy food is accessible in all the communities it serves (transformational).


We’re supporting another system to help homeless patients find supportive housing while we help them design an impact-investment and partnership strategy to address the affordable housing crisis in the first place. Other health systems are working to ensure a living wage for staff, reduce medical debt for patients, offer voter registration for low-income voters, and so on.


In its fullest sense, moving upstream means working along this complete spectrum of improvement — from transactional to relational to transformational. It means articulating clear principles of health equity and justice and identifying concrete opportunities to put these principles in practice. Professions beyond healthcare, from business to law enforcement, are also examining how to make the same shift in their services. That means now is the time for all of us to ask ourselves new questions.


For example: What is our organizational culture? What are our values? As we create new models of integrated health and social care, what is our institution’s role in shaping community conditions and structural forces (e.g. racism, medical debt, income inequality, barriers to voting, etc.) that are at the root of problems such as hunger and homelessness? What can we do to improve them?


On the journey upstream, asking these questions is everyone’s job. Helping leaders answer these questions is the work of HealthBegins and our partners.


At HealthBegins, we believe that moving upstream means better care, stronger connections, and a healthier, more just society. So we make this commitment: Wherever and with whomever we work, we will strive to transform both the relationships and the social structures that influence health, not only the transactions of care.


We invite you to make that commitment, too.

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