June 2019: When moving upstream, don’t go chasing waterfalls


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Vol 2 Issue 6

Dear friends,

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.


Remember back to October 1st, 2013 when the first version of healthcare.gov launched. It didn’t go well. After years of planning and hundreds of millions spent, the site didn’t work. In the first week, only 1% of website visitors were able to successfully enroll for health insurance. Thanks in part to a team drafted to rescue the project, the site was soon fixed. Millions have used it since to sign up for insurance. But the question remained: What went wrong in the first place?


The main culprit, we soon discovered, wasn’t a technical glitch or a person. It was the process. More specifically, the first version of the site failed because those involved used the wrong approach to managing the project and the people behind it. They used the “waterfall” approach, a traditional project management approach widely used in health and human services – by executives, managers, and funders alike. You don’t need formal training in project management to know what a waterfall approach looks like. If you’ve seen a Gantt chart, you get the idea.


The waterfall approach is a linear, rigid process that uses sequential phases to define, build, test, and release project deliverables. Everything (we hope:) moves forward as the project cascades from one step or milestone to the next. For situations where there’s clear agreement among stakeholders about what solution is required, and when there is little technical complexity and a high degree of certainty about how to provide the solution, the waterfall approach to managing teams and projects works great. Building Healthcare.gov, however, was an unprecedented challenge with a high degree of political and technical uncertainty about how best to design the solution. Using a waterfall approach to manage that challenge, as we all learned, was a costly mistake. These days, with stakeholders identifying and implementing complex solutions to address social needs and social determinants of health, the overreliance on a waterfall approach to project development and management is creating a similar risk.


The good news is that there are other, sometimes far more suitable and efficient ways to design, build, test and deploy solutions for these situations. Derived from lean principles, “agile” is a term that covers several of these newer project management approaches. Instead of waiting to see the end result of a lengthy waterfall approach, agile project management uses iterative work cycles and organizes them into mini-phases to rapidly define, build, test, and release project deliverables. This approach accelerates learning about what works and what doesn’t. The use of agile methods not only rescued healthcare.gov, it also led to a surge of innovation in the federal government. For the upstream movement, I think it’s time we all became more familiar with agile methods and when to use them.


As an example, my colleagues and I at HealthBegins recently worked with one of the nation’s largest health systems on an interesting idea. We wanted to define, build and test a new online platform to help community benefits leaders better manage their SDH investments. Instead of mapping out a lengthy Gantt chart, we agreed to use an agile approach. In less than three weeks, we built a solution that showed value. From narrow projects to large-scale initiatives, we’re helping clients and partners across the country learn when and how to use different approaches – waterfall, agile, or a hybrid of both –  to design and manage upstream solutions.


We have a real opportunity to dramatically improve the lives of patients and communities by addressing social needs and social determinants of health. We can’t afford to waste valuable resources, political capital or time. Start by finding agile experts in your own backyard. Ask how an agile approach could be used to develop your upstream solution. Get help to become more versatile as an organization – knowing when to use more traditional approaches to managing people and projects and when to be more agile.


Because sometimes, when moving upstream, it makes no sense to go chasing waterfalls.


I’d love to hear your thoughts. Email us info@healthbegins.org to share your thoughts and learn more about agile vs waterfall approaches to moving upstream.


Rishi Manchanda

This newsletter greeting is adapted from a new blog post. Read more.


From The Upstreamist, the HealthBegins Blog: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 a webinar entitled “Unmuddy the Waters: Healthcare and Social Services Integration”. This blog post summarizes and pulls 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 a little over an hour long.

Upstreamist in Action: In a Texas Clinic, Lawyers Are Health Care Providers

Upstreamist in Action: When a patient at People’s Community Clinic in Austin, Texas, needs something more than routine care, her provider can refer her to the typical roster of specialists: a cardiologist, an orthopedist, a gastroenterologist. Plus one that’s far less typical: a lawyer.


Watch our June Webinar:
Investing for the future: New ways for institutions and communities to fund and manage their upstream investmentsThrough community 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, like increasing screening or reducing ED visits. 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. And one reason is this: As we’re busy designing and managing new upstream initiatives, we’re treating them as individual programs, not as investments within a broader portfolio. National experts discuss new ways for institutions, multi-sector collaboratives and entire communities to shape their interventions into a cohesive investment strategy that can achieve long-term financial, health, and social impact.

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

Upcoming and Recent Events: Find HealthBegins Here

Care Compass Network DSRIP Symposium
June 19 | Ithaca, NY
June 20 | Binghamton, NY
A PPS-wide community event for all who are interested in the challenges and opportunities to improve care and the social determinants of health.

National Quality Forum SDOH Summit
August 5 | Washington, DC

A group of 40 SDOH experts present key discussion points and recommendations on addressing the role of payment in SDOH.

AltaMed All Hands
August 21 | Pasadena, CA

All Hands is an AltaMed company event for their 3k 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:

From Dignity Health:

Dignity Health is issuing out an RFP for a third party entity to create an evaluation design. This design will help scope an evaluation for the Connected Community Network, a program creating linkages for individuals and services that address the social determinants of health.

Click here for further details

From the Robert Wood Johnson Foundation:

Research in Transforming Health and Health Care Systems

2019 Call for Proposals

The 2019 RTHS call for proposals (CFP) seeks to fund research studies that examine how state Medicaid programs are using managed care payment and contracting strategies to address enrollees’ social needs; the ways MCOs are responding; and the effect of these activities on enrollees, plans, community-based organizations, and other stakeholders.

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.

Why I Started Onboard Health

I’m a Latinx Female Founder, and This is How Much Rejection it Took to Get to $27 Million
Fast Company

Screening for Social Needs: Guiding Care Teams to Engage Patients
American Hospital Association

Black Mothers’ Health: How Upending The Typical Grant Funding Structure Is Shifting Power To Improve It
Health Affairs Blog

CMS Approves ‘Netflix’ Model for Hepatitis C Drugs in Louisiana’s Medicaid Program

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