March 2023: What Upstream Transformation Leaders Are Looking for Now

Dear friends,


Over the years, we’ve helped courageous leaders transform their systems by identifying and building specific organizational capabilities to advance equity and move upstream. These days, for example, we’re helping leaders improve REAL data collection and stratification to analyze links between social and health inequities, align payment models and incentives with integrated health and social care, or mobilize colleagues and partners for place-based action to counteract structural drivers of health inequities.


But we’ve found that, beyond these technical endeavors, there’s a social and experiential arc to this transformational work that we cannot ignore. It takes more than a boat, a map, and a paddle to move an organization upstream. The experience of transformation also demands our attention.


We find these days that upstream leaders want to achieve four key results on this path of organizational transformation—each of which also serves as fuel for further advancing equity. And we are working to help our client-partners reach them. Here are the essential, experiential results our partners seek—and how to attain them:


  1. Clarity. As healthcare leaders face growing requirements from federal and state authorities to advance health equity and address social needs, many of them seek clarity about what the requirements are and how those fit within their own organization’s priorities. They frequently also seek clarity about where to start. This includes leaders in Medicaid managed care organizations and health systems and proves especially true for those trying to create or refresh enterprise-wide health equity strategies. How do we get to clarity? At HealthBegins, we do it by applying a rigorous understanding of the structural drivers of health inequities as we support leaders to conduct organizational self-assessments, review data, clarify priorities, draft action plans, and apply a measurement framework to guide their equity-focused transformation. For example, with Hill Country Health & Wellness Center, an FQHC in rural California, we helped clarify how to advance equity in primary care, first by surveying best practices in the field and then deploying an organizational self-assessment tool to help the organization identify its strengths, weaknesses, and a starting point.
  2. Momentum. Once upstream leaders have attained greater clarity about what’s needed, they need to translate their clear understandings into opportunities to generate the momentum, buy-in, and early wins they need to advance equity-focused transformation and improvement. We’ve found that this momentum needs to come quickly, within four to six months of establishing a health equity strategy, to propel the work forward. How? We engage and align key stakeholders to hammer out governance and accountability structures for health equity, identify and break near-term barriers, and design Upstream Quality Improvement campaigns to help them move quickly into tests of change. In our work with USAging, for example, we’re helping Area Agencies on Aging (AAAs) across the nation to build momentum and achieve the equity-focused early wins they’ve prioritized—strengthening internal diversity, equity, and inclusion, increasing community-centered governance, and building healthcare partnerships for health equity.
  3. Acceleration. As vanguard leaders achieve greater clarity and momentum for their health equity efforts, they start looking for ways to accelerate progress—not only toward specific health equity goals for patients and communities, but also toward changes in organizational culture and system transformation. To accelerate organizational transformation requires intentional support and space to assess and nurture an internal culture in which leaders and staff understand health equity through a structural lens and consistently seek ways to embed equity into all aspects of the organization. To reduce specific inequities in clinical performance measures effectively also requires deliberate last-mile strategies for scale and impact. This includes strategies like Community Health Detailing(which we’re currently using with a Medicaid managed care plan serving 2 million members) to accelerate progress in closing particular gaps by tapping into the power of community.
  4. Joy. Upstream work fully succeeds only if it enables us to experience, sustain, and spread joy—the joy that comes with seeing meaningful improvements in health and equity. In our experience, that joy arises through community, through being with fellow Upstreamists within and outside our institutions, and working in solidarity and support together. That is why we make deliberate space in our work to convene people within teams and across the Upstream Movement to share questions, struggles, lessons, and successes. We did this recently, in our webinar with CHCS on “New CMS Guidance and Addressing Social Needs Through Medicaid.” And we will continue to do it without fail, to create space for community so that we can all experience and spread the joy of making progress.



                      Sadena Signature for Public Documents

Rishi Manchanda, MD, MPH.                                         Sadena Thevarajah, JD

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