When I was listening to Rishi Manchanda, M.D., give his TED talk on “upstream medicine” last year, I could not help but think of my nightly conversations with my husband, who practices acupuncture at the local Kaiser Permanente medical center, about his interactions with nearly 30 patients each day. He tells many inspirational stories of people (all with chronic pain conditions) who have overcome so much, but are clearly in need of help with intractable pain.
In his inimitable style, his first questions for his patients are not about what part of their body hurts, but what is going on their lives. With access to sometimes decades of medical history (thanks to Kaiser’s extensive electronic health record system), he is able to ask them about a sick child, the loss of a job, an ailing parent or a recent move. All these life events have a huge bearing on their health and on understanding the “why” behind their visits to his clinic.
After listening to their stories (and making notes to himself), his prescription may be to find a different job, take a vacation, get a dog, enroll a parent in day care or join a gym (in addition to his acupuncture treatments). These are sometimes the “upstream” solutions (at least in part) to their symptoms. “Why,” his patients ask him, “has no one ever asked me these questions or listened to me?”
More Than Just Pain
Studies have shown that complex social and psychological factors are at play, and they seem to help determine who fares well, despite even severe chronic pain, and whose lives quickly unravel. Negative emotions, including sadness and anxiety, seem to aggravate chronic pain. For example, people who dwell on their discomfort tend to be more disabled by chronic pain than people who try to take their pain in stride. And among people with chronic pain stemming from a work-related injury, those who report poor job satisfaction fare worse than those who say they like their jobs. On the other hand, some physicians believe being in constant pain can cause depression.
Back to Manchanda, a physician practicing in south-central Los Angeles: In his TED talk, he tells the story of Veronica, a patient who went to the emergency department several times for migraine headaches. When the standard treatments and tests failed to help or reveal anything unusual, she was referred to Manchanda’s clinic where, after some probing, they were able to discover that her apartment was full of mold and was causing an allergic reaction.
The upstream approach to health care takes this approach to the next level. Clinicians like Manchanda are not just identifying the causes of discomfort, but are working with the necessary people — community health workers, housing advocates, nutritionists or other appropriate professionals — to make change happen. Manchanda’s organization, Health Begins, trains physicians in identifying and addressing the upstream determinants of health.
I spoke to Heidi Behforouz, M.D., an upstreamist innovator who has worked with chronically ill patients at Boston’s Brigham and Women’s Hospital. She found that much of the medical therapy given to these individuals was not working — not because the treatment was ineffective, but because of their struggles with housing, lack of insurance, legal status or other problems. She says hospitals cannot ignore the new population health payment models that will require them to think differently about how they care for their patients, not just in the hospital setting but where the patients live and work. Addressing these issues not only helps to avoid unnecessary hospital care, which is costly, but serves their organizational mission.
Many large health systems such as Kaiser Permanente and Dignity Health are addressing the new value-based payment models head-on with massive investments in the communities they serve. For example, according to its 2015 annual report on mission integration, Dignity Health has, since its inception, awarded about $56 million in grants and invested more than $179 million in loans for initiatives that, among other actions, address obesity and housing as well as offer microlending in the communities they serve.
Innovation in New England
One example of a hospital that is moving outside its walls to listen to the needs of its constituents and identify ways to address them upstream is Saint Francis Hospital and Medical Center in Hartford, Conn. I always thought of Hartford as the insurance capital of the world, but little did I know it is one of the poorest cities in America. Thirty-two percent of the population live below the poverty line, and one-third of the residents do not have a high school degree.
Marcus McKinney, vice president of community health equity at Saint Francis, tells me that the hospital’s journey started when one of its board members, a successful businessman and cancer survivor, relayed to the board his conversations with other men he had spoken with during his walks through the ED. The board member, Curtis Robinson, found that many of the concerns and needs expressed by these men were not being addressed by our current health care delivery system.
Robinson’s passion led to the establishment of a men’s health center that reaches out to churches, shelters and other places in the community. Center staff listen to the men’s concerns and offer them solutions. The mission of the center began with a focus on cancer, but gradually expanded to address women’s and children’s health. Gradually, the program grew into the Curtis D. Robinson Center for Health Equity, whose purpose was to bring together community members, public policymakers, health providers and other local stakeholders to address health inequities.
Today, says McKinney, the center is a bridge between the world of health care and the community — and a powerful tool that helps to promote greater understanding. Learning needs to go both ways, McKinney maintains, so that health professionals listen and learn while they educate their constituents.
By taking a step back — or rather upstream — these practitioners and their organizations are leading the way for others. They are not only complying with the requirements of the Affordable Care Act, but are making a profound impact on health care costs, quality and the lives of those they serve.
Sita Ananth, M.H.A., is a Napa, Calif.-based consultant and writer specializing in complementary medicine and wellness. She is also a regular contributor to H&HN Daily.