July 2019: The next level of upstream care


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Vol 2 Issue 7

Dear friends,

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 poor public transit makes it hard for him to attend the lesson? What if the pond is polluted? Why not teach a woman to fish? What if he or she has no fishing rod or needs to present a fishing license that only privileged people can acquire?” 

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 get the patient the help they need. These days I meet more and more executives, vendors, and even investors with newfound interest in health-related social needs, a desire to derive good 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, and between healthcare and community leaders. We released the Upstream Communication Toolkit to support these relationships. My colleagues and I recognize that this is part of the magic of moving upstream: it builds stronger human connections. 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 personalized transactions between healthcare and social services, delivered through deep and respectful 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 those systems is what we and our partners in upstream care must tackle now. In fact, we’ve already started. 

For example, one of our 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 housing while designing an investment and partnership strategy to help address the affordable housing crisis in the first place. Other health systems are working to ensure a living wage for staff, to reduce medical debt for patients, to offer voter registration for low-income residents, and so on.


In its fullest sense, moving upstream means working along this complete spectrum of improvement — from transactional to relational to transformational. That’s why, in our work, we’re helping healthcare and social service leaders improve health-related social needs while taking a more critical look at ways their own institutions can promote equitable, healthy relationships and systems.


Professions beyond healthcare, from business to law enforcement, also are striving to move from transactional to relational and transformational ways of serving people and communities. Now’s the time for all of us to ask ourselves new questions.


For example: What is our organizational culture? What are our values? Are we providing the best, most equitable care to those who need our help? 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 like hunger and homelessness? What can we do to improve them?


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.


Rishi Manchanda


From The Upstreamist, the HealthBegins Blog:When Moving Upstream, Don’t Go Chasing Waterfalls

With so many emerging initiatives and projects to address social needs & social determinants of health, the opportunity to improve the lives of patients and communities is more real than ever. But we face a real risk of squandering this opportunity.

Time to Manage Upstream Programs Like Investments

Through partnerships and collaboratives, healthcare organizations are launching programs to address social needs and social determinants of health. We have budgets and plans to reach specific goals, but is the way we’re spending our resources putting us on a path to achieve long-term goals for community health? At the moment, the answer is no. In this blog post, Rishi Manchanda outlines why it’s time to view upstream interventions as investments for long-term financial, health, and social impact.

Unmuddying the Waters: A Webinar Recap

On April 24th, we hosted the webinar: “Unmuddy the Waters: Healthcare and Social Services Integration.” This blog post summarizes key lessons from that event.

If you missed it, you can watch the webinar here. Note: You’ll be asked to input some information in order to access the video. The webinar is about an hour long.



Share the risk, share the rewards of partnership: The new Commonwealth Fund ROI Calculator to Address SDOH
Wednesday, July 31, at 9:30 a.m. PT / 12:30 p.m. ET
Healthcare and community-based organizations are well on their way to partnering for better care in their communities, yet designing sustainable financing mechanisms for these partnerships remains a challenge. Last week, the Commonwealth Fund launched a new version of the ROI calculator for partnerships, built by Dr. Victor Tabbush, Senior Fellow at HealthBegins. Over a year ago, Dr. Tabbush first took the HealthBegins community through a structured way to calculate the risks and rewards of partnership. Now you can join us on July 31 to hear national experts from HealthBegins, the Commonwealth Fund, and the Nonprofit Finance Fund discuss the newest version of this tool, and to learn from their experience in building sustainable partnerships.

Register Here


  • Rishi Manchanda, MD, MPH, President, HealthBegins
  • Victor Tabbush, PhD, Adjunct Professor Emeritus, UCLA Anderson School of Management
  • Tanya Shah, MBA, MPH, Vice President, Delivery System Reform, Commonwealth Fund
  • Kristin Giantris, MPA, Managing Director, Consulting, Nonprofit Finance Fund

By the end of the webinar, participants will be able to:

  • List at least two benefits of using the calculator that are relevant for partnership work, drawing in part from experiences of the ROI Calculator’s first cohort of Super Users
  • Describe the new version of the Calculator, including the new resource materials available  
  • Understand how to stay engaged and access upcoming resources related to the Calculator

Cost: This webinar is free!

Can’t attend the live event? By registering, you will be able to access a recorded version of the webinar later.

Questions? Email us at info@healthbegins.org.

Interested in more webinars from HealthBegins? You can find recordings of all of our past webinars here.

Upcoming and Recent Events: Find HealthBegins Here

National Quality Forum SDOH Summit
August 5 | Washington, DCForty SDOH experts present key discussion points and recommendations on addressing the role of payment in SDOH.

AltaMed All Hands
August 21 | Pasadena, CA

A company event for AltaMed’s 3,000 employees, including providers.

Presenting powerful upstream results at an upcoming conference? Nominate yourself to be featured as a HealthBegins Upstreamist in Action at info@healthbegins.org.

Upstream Opportunities:

Sept. 10, 2019, at 3 p.m. ET
Free webinar from Community Benefit Connect: “Nonprofit Hospital Community Benefit Spending and Readmission Rates.” Krisda Chaiyachati, MD, MPH, MSHP, of the University of Pennsylvania, presents first-of-its-kind research on the association between community benefit spending on community needs and lower Medicare readmission rates.

Register here.

If you have fellowships, events, or other opportunities you’d like us to share, please email us at info@healthbegins.org.

Upstream News

Curated highlights of happenings affecting upstream care. Links are not endorsements.

Moving Upstream: Addressing Social Determinants of Health
Harvard Medical School Center for Primary Care

For An Option To Address Social Determinants Of Health, Look To Medicaid
Health Affairs Blog

The Economist Who Would Fix the American Dream
The Atlantic

Social Determinants Accelerator Act
Congresswoman Cheri Bustos

CVS and Aetna to Launch Social Care Network
Modern Healthcare

Census 2020—A Preventable Public Health Catastrophe
American Public Health Association (APHA) publications

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