March 2019: How Far We've Come


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Vol 2 Issue 3

Dear friends,

Six years ago, I wrote a book titled The Upstream Doctors. At the time, few of us in healthcare were engaged in efforts to look upstream, to tackle sickness at its source.


Times, since then, have changed.


In a few days, I’ll have the opportunity to address America’s Physician Groups, a network representing hundreds of US medical groups moving into value-based care delivery. The topic? The social determinants of health.


Now more than ever, physicians understand that the accumulated research on social determinants of health is definitive. The social and environmental conditions that shape where and how we live, eat, sleep, learn, and work also play a major role in shaping health outcomes —from the burden and distribution of disease to how long we live.


And as our collective understanding of social determinants of health has grown, so has our understanding as to what working in this space actually entails, for physicians and for us all.


We know that communicating with precision is critical. For example, when many healthcare leaders these days use the term “social determinants of health,” they are often referring to what may be better defined as “health-related social needs” or better yet, “social needs” — the ways in which the broader phenomena of social determinants of health and equity manifest in the lives of individual patients. We’re learning that physicians have a key role to play in clinics and communities, whether helping to address social needs for specific patients or social determinants of health for the nation. And it starts with clearer communication.


Beyond just using more precise language, physician groups and other healthcare organizations are learning to apply more rigor as they start the journey upstream. From assessing internal capabilities and developing screening and referral workflows to refining strategies for data collection and setting partner roles and expectations, the domains of work are more clear now than ever before.


We’ve begun to convert these early learnings into rigorous frameworks and tools. In our upcoming April webinar, for instance, we’ll be diving into our “Levels of Social Determinants of Health (SDH) Integration Framework.” Developed with input from leaders around the country, this “Rosetta Stone” framework helps healthcare and human service partners think more clearly about their SDH work not as a single effort but as a spectrum of work, with basic service coordination on one end to full integration of services on the other.


And, as the strongest sign of where we are, we’re seeing vanguard organizations leverage their performance improvement experience and resources to launch cross-sector “Upstream Quality Improvement Campaigns.” With support from HealthBegins and our partners, healthcare and community partners across the country are using the knowledge of social determinants and the power of continuous learning and improvement methods to transform their approach to individual care and community health.


Questions remain, of course, particularly those related to the alignment of internal organizational priorities with broader community goals. But the good news is that across the country, the shift is noticeable.


Six years ago, I profiled a handful of vanguard clinicians who illustrated why moving upstream to improve care and social determinants of health was critically necessary. Now, with America’s Physician Groups joining in, a broad swath of healthcare stakeholders are beginning to engage public health and social sector partners, eager to show us that moving upstream is not only necessary, but that it’s possible.



Rishi Manchanda


More from The Upstreamist, the HealthBegins Blog:

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.

Mincing Words: Making Sense of the Social Determinants of Health

With so many organizations getting interested in addressing the social determinants of health, the definitions can get muddy. In this recent interview and video with the Institute for Healthcare Improvement, HealthBegins founder Rishi Manchanda clarifies the meaning of this crucial work and connects it with pursuit of the Triple Aim and joy in work.

New Hope, Timeless Values: What Happened When HealthTech 4 Medicaid Went to Church

The HealthBegins team went to San Francisco this month to join the 2nd Annual Future of Medicaid Innovation Forum. In a church with a historic past, we sat in fellowship with hopeful, determined entrepreneurs working to improve Medicaid through tech. Our post explains what we saw, learned, and will carry with us.


Look for a new HealthBegins webinar coming in April!

Have a topic that you’d love to see us cover in a webinar?
Please tell us! Email at

Upcoming Events: Find HealthBegins Here

April 11 | WilliamsburgHealthcare providers and leaders share best practices and discuss how to best address the social determinants of health.

2019 IHI Patient Care Summit
April 12 | San Francisco

Healthcare professionals explore how quality improvement methods can be used to achieve better outcomes in primary care.

America’s Physician Groups Annual Conference 2019
April 13 | San Diego

Attendees will hear from leading speakers about the current state of healthcare and will gain the information and tools needed to thrive in multiple payer arrangements: MIPS, APMs, commercial, and Medicaid.

2019 CIE Summit
April 25 | San Diego

Forward-thinking speakers, panelists, and participants engage in a powerful discussion around best practices and data sharing to create healthier communities.

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

Upstream Opportunities

From the California Improvement Network:

If you have fellowships, events, or other opportunities you’d like us to share, please email us at

Upstream News

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

Court slams UnitedHealth for restricting access to mental health care to save money
MPR News

Most hospitals receive failing score in at least 1 quality dimension of their community health needs assessment

California needs more health care providers
The Daily Californian

Kaiser, Dignity Health executives: Better strategy needed to get ROI from social determinants initiatives

What swung conviction of ex-cop Nouman Raja? Audio of his deadly encounter with Corey Jones.
Sun Sentinel

How are states addressing primary care quality in medicaid managed care?
The Commonwealth Fund

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