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.

Best,

Rishi Manchanda

AltaMed All Hands
August 21 | Pasadena, CA

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

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.

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