Bridging Health and Health Care: Confessions of an "Upstreamist"

Mar 20, 2014, 8:40 AM, Posted by Susan Dentzer

The Upstream Doctors

A key aspect of the Robert Wood Johnson Foundation’s new “culture of health” focus is “bridging” the two worlds of population health and health care. One component of that bridge—arguably, its abutment—rests in the nation’s more than 100 academic health centers (AHC’s).

These schools of health and medical professional education, linked with owned or affiliated teaching hospitals and health systems, have long concentrated on the invention and provision of intensive, costly, and high-tech medicine. But now some of these centers are also building bridges upstream—focusing on incomes, housing, transportation, and other social forces that are the primary drivers of health.

Leaders in this movement recently convened at Georgetown University in Washington, D.C., for the third national conference of Academic Health Centers and the Social Determinants of Health.

Under the auspices of the Association of Academic Health Centers, and in partnership with the Centers for Disease Control and seven leading AHCs, the conference explored ways in which the centers are reaching beyond their walls to influence and affect the fundamental determinants of health.

Among those urging the audience to become “upstreamists” —health professionals focused on the social and environmental conditions that drive health and illness—was Rishi Manchanda, the lead physician at a Los Angeles community clinic for homeless veterans. He is also president and founder of HealthBegins, a startup that helps educate health professionals about addressing patients’ and communities’ social and environmental needs. On the HealthBegins web site, or at workshops that the organization sponsors, clinicians can learn how to query patients about their housing, food, or other needs, and refer them to sources of assistance, such as food banks. “Treating patients without tackling the conditions that make them sick is a losing proposition and is substandard care,” Manchanda told the conference.

As in his TED Book, The Upstream Doctors, Manchanda recounted the story of a former patient, Veronica, from South Central Los Angeles, who suffered from severe chronic headaches. Different health care providers she had seen ordered three diagnostic CT scans and performed countless blood tests; finding nothing, they prescribed pain medications and suggested further evaluation if needed. One emergency room visit cost Veronica one-and-a-half times her monthly rent.

At Manchanda’s clinic, by contrast, a medical assistant asked questions derived from the American Housing Survey that helped identify a key issue: Veronica’s rental apartment was roach-infested. Suspecting chronic nasal allergies and sinus headaches, Manchanda referred her to a tenant’s rights group and community development agency, which helped pressure the landlord to remedy the roach infestation. When Veronica  returned to Manchanda’s clinic three months later, her allergies had improved and her headaches were gone.

“Upstreamist” clinicians, said Machanda, should ask patients like Veronica about where they live, work, eat, and play; should record relevant information using electronic health records and other tools; should integrate interventions addressing social and economic determinants of health into their clinic work flow; and should address these determinants at the individual patient, clinic, and population levels. His message found a receptive audience among the academic health center leaders present, who described their efforts to educate a new generation of “upstreamists” at their respective institutions.

Consider Florida International University, where medical, nursing, social work, public health and law students participate in an interprofessional program that takes them to underserved neighborhoods in Miami-Dade County. Paired with one to two underserved households for as long as four years, the teams make regular home visits and develop comprehensive plans for treatment of any health conditions as well as prescriptions for health-improving measures.

The relationships that form afford students “total immersion in real families with real problems,” says Pedro Jose’ (“Joe”) Greer, a physician who directs the program, Green Family Foundation NeighborhoodHELPTM (and is also assistant dean for academic affairs at FIU’s medical school). A program evaluation recorded significant decreased visits to hospital emergency rooms and increased preventive health measures, and is projected to save $8 in medical costs for every dollar invested.

These and other examples discussed at the conference suggest that a “paradigm change has begun to take hold,“ said Ron Berkman, president of Ohio’s Cleveland State University, which among other initiatives is restructuring its undergraduate pre-medical curriculum to focus more on population health. Many other issues still need to be addressed as academic medical centers embrace the evolving field, including assembling a better evidence base for which measures can best improve health. But there’s little doubt that, at a number of AHCs, the bridge connecting health care and upstream health determinants is now under construction—one student, clinician, and needy family at a time.