Upstreamists in Action: Upstreamists are changemakers pioneering practices that improve health by blending medical and social care. In this series of profiles, HealthBegins highlights some of these bold leaders and their innovations, in settings large and small. Their stories show us that the journey upstream is not only necessary — it’s possible.

Advice for other upstreamists:
“Start small. It’s overwhelming, but start with one pilot and really think through what are the metrics, how can we prove our ROI, and not only financially. … Here’s your public-relations twist: You’ve gotta know your audience. Your program has many facets to it, so you might have to be more data-driven in your sell, or more heart-driven, or make a more financial sell, depending on who your audience is.”

Ms. Saunders’s story:
The upstream-medicine effort at Dayton Children’s Hospital in Ohio started in the unlikeliest of places: the marketing department.

The effort is now a fully established hospital initiative. It has acquired a formal management team, spawned a new social-service navigation program, and launched a construction project to facilitate integration of that program with primary care. But it began almost coincidentally, with a strategic planning process for community health work.

Jessica Saunders, the unlikely Upstreamist who spearheaded the effort, had been leading the hospital’s community outreach efforts for about eight years when it all began. She had previously run injury prevention campaigns and worked the education table at health fairs. As community needs assessments and community benefit reporting grew more important, those tasks became part of her work, too.

“I always joked that it was my job to keep people out of the hospital, even though I was in marketing,” Saunders says.

​She already held a master’s degree in public administration from University of Dayton, where her coursework entailed deep work in local communities, integrating residents’ voices into policies that would affect their future. Her Upstreamist’s spirit, in other words, was already there.

Then, about three years ago, two events launched her directly into upstream medicine. First, a community health needs assessment, completed as part of that strategic planning process, identified some of Dayton’s most pressing health concerns: high rates of asthma, food insecurity, infant mortality, and childhood diabetes.

The results sparked an “aha” moment for Saunders and her colleagues about the social determinants of health. “We really realized that there are community resources, but so many families were lacking the connection that they needed” to those resources, Saunders recalls. “Someone can’t concentrate on their health or their child’s health if they don’t have food on the table.”

Around the same time, hospital CEO Deborah Feldman went to a conference and came back with an epiphany: Dayton Children’s needed a center for all the community health work they were doing, and Saunders should be the director.

Soon after, the hospital CMO found a like-minded physician, child-abuse pediatrician Dr. Jonathan Thackeray, and made him Saunders’s medical partner. He would guide the clinical side of the upstream effort, while Saunders guided the community side. Their mission was launched.

Upstream HQ:
The engine of Dayton Children’s growing upstream effort now is a new program called the Family Resource Connection (FRC) that’s meant to serve as the missing link between services and families with social needs. Saunders designed the program in collaboration with hospital social workers and with lessons learned in an online class from Health Leads.

Whenever a patient needs additional resources to sustain good health — for example, a family needs a stable food source, or an inpatient needs clean clothing — hospital staff can refer them to the FRC. There, a trained student-advocate, supervised by a behavioral health coordinator, contacts the patient or family by phone, text, or email and works to connect them to the right community resource.

The students staffing the FRC hail from disciplines as diverse as social work, public health, pre-med, and healthcare administration, and that’s intentional; the program aims to teach them to look upstream and break down their siloes right away.

​Primary Care and Beyond:
Any department can refer to the FRC, but its proving ground has been Dayton Children’s Pediatrics. The primary care clinic sees about 6,000 patients a year, three-quarters of them on Medicaid.

When the FRC launched in summer 2016, just one physician was screening children for social needs. Now, the pediatric clinic uses a social-needs screening form to screen every child at every well-child visit. When a social need appears on that form, the physician discusses the need with the family and lets them know that they’ll hear from the FRC

Pediatric primary care is only the beginning. Saunders’s team is now piloting social-needs screening in the hospital nutrition clinic, with plans to continue expanding the practice into new departments over time.

For now, space constraints dictate that the pediatric clinic and the FRC operate in separate parts of the hospital. But Dayton Children’s is working to put them together. When the Center for Community Health and Advocacy is complete, in spring 2019, families will find pediatric primary care, the FRC, and a food pharmacy all in one place.

​Constant Improvement:
Saunders’s journey upstream was fueled in part by Quality Improvement (QI) — a systematic approach to continually improving healthcare practice — and that spirit of ongoing refinement continues to define her upstream work.

HealthBegins’s presentations on Upstream QI have helped Saunders shape protocols to measure and strengthen the impact of new programs. Dayton Children’s also offers staff members a nine-month QI class, and Saunders joined it just as she was starting the FRC. “I’m really thankful,” Saunders says, “because my mind kind of works in QI and constant improvement, but I was in marketing.”

One of the clearest impacts of QI so far is on scripting. At first, examining the data, Saunders found that families in the FRC program didn’t necessarily have better outcomes. So she and her team worked to refine the scripts that advocates use with families. Then she used the data to show the advocates how much difference a good script made.

Careful QI also taught the FRC team that the best frequency and mode of communication depends on the individual family, and that it’s most effective and efficient to give families the chance to choose what contact they want.

To Saunders, this work demonstrates the value of QI even beyond the clinic. “It shows that you can use those QI practices in a social service setting, as well.”

Families, Connected:
​In the two years since the FRC opened, caregivers in the pediatric clinic have screened more than 4,500 patients for unmet social needs. Nearly one in three patients has had at least one.

​Among families referred to the FRC, advocates have been able to verify that one in five actually accessed a community resource that the center recommended. Soon, Saunders’s team will be able to connect that information with clinical outcomes data to determine how successfully those resources are improving patients’ health.

These days, Saunders’s QI work is focused on closing the communication loop — ensuring, for example, that the family did in fact access the food pantry and that the referring physician knows they did. Integrating these social-service connections into the electronic health record is another key project in progress.

The advocates, meanwhile, continually learn from the families they serve, identifying gaps in services that the hospital and community need to fill. In this way, the advocates’ upstream work flows in two directions; they inform hospital policy and address the social determinants of health for the whole community, as well as for individuals.

And that, Saunders’s story shows, is why caregivers who are connected to the community — be they clinicians or custodians or marketers — are empowered to address sickness at its source.

“When I think of the evolutions, it’s gone from sitting at a health fair to social-determinants-of-health screening,” Saunders says. “And I think it follows the evolution of where healthcare has gone and is going.”

Learn how HealthBegins can help you move healthcare upstream. Contact us to learn more.