Moving Upstream: Addressing Social Determinants of Health

July 18, 2019

Perspectives in Primary Care (formally the Primary Care Review) features perspectives from practitioners and students representing organizations, practices, and institutions across the country and around the world. All opinions expressed in this article are owned by the author(s).

The Primary Care Improvement Network (PCIN) is a membership-based network focused on supporting practice transformation, quality improvement, leadership skills, and the dissemination and spread of best practices. The program brings together important primary care stakeholders to address ongoing health care challenges. The goal of the program is to develop high-performing interdisciplinary teams to engage the PCIN themes of 2019-2020, which include effective implementation of telemedicine and effectively address health-related social needs. In the Primary Care sphere, there is increasingly talk about moving “upstream” to improve health and reduce health care costs such as working to prevent disease before it happens by addressing the social and environmental determinants of health.

Among those championing this upstream approach is Rishi Manchanda, M.D. Manchanda argues for Upstreamists - physicians who see their work as including a “duty not only to prescribe a clinical remedy but to tackle sickness at its source.” Manchanda is a nationally known advocate of healthcare that looks beyond the clinic and into the lives of the people he serves. Manchanda founded Health Begins, a non-profit organization that offers training designed to “equip healthcare professional to design successful upstream solution to improve care at a lower cost.”  In his talk at PCIN, he contends that the U.S. healthcare system is failing patients by treating disease without addressing the social factors that lead to illness and injury. Today’s health care problems are rooted in individual health choices shaped by the many contexts in which people live; therefore, medicine and public health simply cannot afford to continue to work in their separate silos.

The approach Manchanda recommends is the “Get Ready, Get Set, Go Upstream” approach. The “Get Ready” element involves hospitals assessing their baseline level of readiness to address patients’ health-related social needs. That starts with a readiness assessment to see how capable the organization is to address health-related social needs. The second part is to “Get Set.” That means to review the results, not only internally with key groups, leaders and front-line staff, but also with partners in the community who work on upstream issues. For instance, if one of the hospital's key strategic priorities is to improve outcomes for patients with diabetes, it is important to acknowledge the strong link between food insecurity and diabetes. What if that hospital worked with an upstream partner like a food bank or agency that deals with food insecurity? Hospitals can review their data sources to identify unmet social needs and review existing staffing capabilities that will help them home in on at least one key patient population and one key social determinant like food insecurity, where they and their upstream partners believe they can achieve the greatest impact.  The “Go Upstream” step allows hospitals to launch an upstream quality improvement project with a partner that goes after a key area of improvement for a specific population and social determinant. By using this three-step approach for specific populations creates practical readiness and capability, as the efficacy and effectiveness of the hospital system start to improve.

Manchanda adopted the “Get Ready, Get Set, Go Upstream” approach from his experience as a clinician. He has always been involved in caring for vulnerable populations — whether it's low-income families in South Central Los Angeles, which was his first major clinical job, or taking care of homeless veterans at the VA. He had health care jobs that always required him to think about how to provide the best care and the best outcomes for vulnerable populations. In the front lines of clinical care, it’s hard not to see the impact of these unmet social needs.

The first part of the approach is about making the case for social determinants themselves. The next step is to define how these issues impact health care. At times, health care providers will say, “We understand that where people live and where they work plays a huge role in health, but our role is to take care of people when they're sick. We’re not community organizers, urban planners, workers or transportation specialists.” However, if you have a patient who routinely comes in and out of the emergency department, often the major driver of that are nonmedical needs. It tends to be linked to something like a lack of housing, food insecurity, or social isolation. Those are nonmedical needs but are vital to health outcomes. Many hospitals that view social determinants as external to core operations are starting to realize that these unmet social needs actually play a vital role in the operations themselves. Manchanda exclaimed that hospital financial advisors say, “How can we afford to do this?” In response, Manchanda challenges the health care systems to say, “How can we afford not to do this?” By not screening for and addressing the vital social needs of populations we serve, we actually create more inefficiency and more missed opportunities to provide better care. And if we quantify those missed opportunities, we know that there is a huge cost.

Manchanda exclaimed that “Upstreamist” model speaks to the importance of taking the tools that hospitals already have, including quality improvement measures, to address the upstream drivers of poor health, and apply them to the root causes of major health care problems. The elements of a “Get Ready, Get Set, Go Upstream” approach can help us to select and use upstream quality improvement methods, along with the tools, training and technical assistance, to improve the readiness and capability of hospitals to address upstream issues.


About the author

Priyanka K. Naithani is a junior at Clark University, pursuing International Development and Political Science. She aspires to work in public policy to promote women’s rights, improve the quality of healthcare, and support social entrepreneurship/innovation.

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