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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Page R13
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/26059.
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Models for Population Health Improvement by Health Care Systems and Partners Tensions and Promise on the Path Upstream PROCEEDINGS OF A WORKSHOP Melissa Maitin-Shepard, Rapporteur Roundtable on Population Health Improvement Board on Population Health and Public Health Practice Health and Medicine Division PREPUBLICATION COPY—Uncorrected Proofs

THE NATIONAL ACADEMIES PRESS   500 Fifth Street, NW   Washington, DC 20001 This activity was supported by contracts between the National Academy of S ­ ciences and the Association of American Medical Colleges, Blue Cross and Blue Shield of North Carolina, The California Endowment, Dartmouth-Hitchcock, Department of Health and Human Services Program Support Center, Geisinger, Kaiser Permanente, The Kresge Foundation, Nemours, The Rippel Foundation/ ReThink Health, Robert Wood Johnson Foundation, and Wake Forest Baptist Health. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project. International Standard Book Number-13: 978-0-309-XXXXX-X International Standard Book Number-10: 0-309-XXXXX-X Digital Object Identifier: https://doi.org/10.17226/26059 Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2021 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Models for population health improvement by health care systems and partners: Tensions and promise on the path upstream: Proceedings of a workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/26059. PREPUBLICATION COPY—Uncorrected Proofs

The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institu- tion to advise the nation on issues related to science and ­ echnology. Members t are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president. The National Academy of Engineering was established in 1964 under the char- ter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president. The National Academy of Medicine (formerly the Institute of Medicine) was estab­ished in 1970 under the charter of the National Academy of ­ ciences to l S advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president. The three Academies work together as the National Academies of Sciences, E ­ ngineering, and Medicine to provide independent, objective analysis and a ­ dvice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in ­ atters of science, engineering, and medicine. m Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org. PREPUBLICATION COPY—Uncorrected Proofs

Consensus Study Reports published by the National Academies of Sciences, Engi­eering, and Medicine document the evidence-based consensus on the n study’s statement of task by an authoring committee of experts. Reports typi- cally include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task. Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opin- ions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies. For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo. PREPUBLICATION COPY—Uncorrected Proofs

PLANNING COMMITTEE ON HEALTH CARE SYSTEM APPROACHES TO POPULATION HEALTH: TENSIONS AND PROGRESS1 MARC N. GOUREVITCH (Chair), Chair, Department of Population Health, New York University Langone Health PHILIP M. ALBERTI, Senior Director, Health Equity Research and Policy, Association of American Medical Colleges SALLY A. KRAFT, Vice President of Population Health, Dartmouth- Hitchcock Medical Center SANNE MAGNAN, Senior Fellow, HealthPartners Institute RAHUL RAJKUMAR, Senior Vice President and Chief Medical Officer, Blue Cross and Blue Shield of North Carolina LOURDES J. RODRIGUEZ, Senior Program Officer, St. David’s Foundation Health and Medicine Division Staff ALINA BACIU, Roundtable Director CARLA ALVARADO, Program Officer (until January 2021) BRITTANY DAVENPORT, Senior Program Assistant (until December 2019) HARIKA DYER, Senior Program Assistant (from April 2020) 1 The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility ­ for the published Proceedings of a Workshop Series rests with the workshop rapporteur and the ­institution. v PREPUBLICATION COPY—Uncorrected Proofs

ROUNDTABLE ON POPULATION HEALTH IMPROVEMENT1 SANNE MAGNAN (Co-Chair), Adjunct Assistant Professor, Division of Medicine, University of Minnesota JOSHUA M. SHARFSTEIN (Co-Chair), Associate Dean for Public Health Practice and Training, Johns Hopkins Bloomberg School of Public Health PHILIP M. ALBERTI, Senior Director, Health Equity Research and Policy, Association of American Medical Colleges JOHN AUERBACH, Executive Director, Trust for America’s Health CATHY BAASE, Chair, Board of Directors, Michigan Health Improvement Alliance; Consultant for Health Strategy, The Dow Chemical Company RAYMOND BAXTER, President and Chief Executive Officer, Blue Shield of California Foundation DEBBIE I. CHANG, Senior Vice President, Policy and Prevention, Nemours MARC N. GOUREVITCH, Professor and Chair, Department of Population Health, New York University Langone Health GARTH GRAHAM, President, Aetna Foundation GARY R. GUNDERSON, Vice President, Faith Health, School of Divinity, Wake Forest University WAYNE JONAS, Executive Director, Integrative Health Programs, H&S Ventures, Samueli Foundation ROBERT M. KAPLAN, Professor, Center for Advanced Study in the Behavioral Sciences, Stanford University DAVID A. KINDIG, Professor Emeritus of Population Health Sciences, Emeritus Vice Chancellor for Health Sciences, School of Medicine and Public Health, University of Wisconsin–Madison MICHELLE LARKIN, Associate Vice President, Associate Chief of Staff, Robert Wood Johnson Foundation PHYLLIS D. MEADOWS, Senior Fellow, Health Program, The Kresge Foundation BOBBY MILSTEIN, Director, ReThink Health JOSÉ T. MONTERO, Director, Office for State, Tribal, Local and Territorial Support, Centers for Disease Control and Prevention KAREN MURPHY, Executive Vice President and Chief Innovation Officer, Founding Director, Steele Institute for Healthcare Innovation, Geisinger 1 The National Academies of Sciences, Engineering, and Medicine’s forums and round- tables do not issue, review, or approve individual documents. The responsibility for the pub- lished Proceedings of a Workshop rests with the workshop rapporteur and the institution. vi PREPUBLICATION COPY—Uncorrected Proofs

RAHUL RAJKUMAR, Senior Vice President and Chief Medical Officer, Blue Cross and Blue Shield of North Carolina LOURDES J. RODRIGUEZ, Director, Center for Place-Based Initiatives, Dell Medical School; Associate Professor, Department of Population Health, The University of Texas at Austin PAMELA RUSSO, Senior Program Officer, Robert Wood Johnson Foundation MYLYNN TUFTE, State Health Officer, North Dakota Department of Health HANH CAO YU, Chief Learning Officer, The California Endowment Health and Medicine Division Staff ALINA BACIU, Roundtable Director CARLA ALVARADO, Program Officer BRITTANY DAVENPORT, Senior Program Assistant (until December 2019) HARIKA DYER, Senior Program Assistant (from April 2020) Consultant MELISSA MAITIN-SHEPARD, Rapporteur vii PREPUBLICATION COPY—Uncorrected Proofs

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Reviewers This Proceedings of a Workshop was reviewed in draft form by indi- viduals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineer- ing, and Medicine in making each published proceedings as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the charge. The review com- ments and draft manuscript remain confidential to protect the integrity of the process. We thank the following individuals for their review of this proceedings: JESSIE HECOCTA, Blue Zones Project, Healthy Klamath VINU ILAKKUVAN, PoP Health, LLC Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the content of the proceedings nor did they see the final draft before its release. The review of this proceedings was overseen by GEORGE J. ISHAM, H ­ ealthPartners Institute. He was responsible for making certain that an independent examination of this proceedings was carried out in accor- dance with standards of the National Academies and that all review com- ments were carefully considered. Responsibility for the final content rests entirely with the rapporteur and the National Academies. ix PREPUBLICATION COPY—Uncorrected Proofs

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Contents ACRONYMS AND ABBREVIATIONS xi 1 INTRODUCTION 1 Workshop Objectives, 1 Organization of the Workshop and Proceedings, 3 A Metaphor for Framing the Workshop, 4 2 OVERVIEW OF THE LANDSCAPE: TENSIONS AND PROMISE 5 Activities in the Health Care Sector to Improve Social Care and Strengthen Social Resources, 8 Opportunities for Health: Addressing Social Determinants of Health, 12 Audience Discussion, 16 3 HOW LEADERSHIP AND ORGANIZATIONAL STRUCTURE CAN ADDRESS HEALTH-RELATED SOCIAL NEEDS AND ADVANCE HEALTH EQUITY 19 Redesigning a Health System to Create Well Communities, 19 Enterprise-Wide Infrastructure to Advance Health Equity, 21 Audience Discussion, 22 xi PREPUBLICATION COPY—Uncorrected Proofs

xii CONTENTS 4 DOWNSTREAM: ADDRESSING PATIENTS’ HEALTH-RELATED SOCIAL NEEDS 25 Rush System for Health: A Case Study for Health Equity, 25 Many Voices: One West Side, 27 Audience Discussion, 30 5 MIDSTREAM: ACCOUNTABLE HEALTH COMMUNITIES AND PARTNERSHIPS WITH HUMAN SERVICES ORGANIZATIONS 33 The Denver Regional Accountable Health Community, 33 Partnerships with Area Agencies on Aging and Other Community-Based Organizations, 35 Audience Discussion, 38 6 UPSTREAM: CHANGING ENVIRONMENTS, CHANGING POLICY 43 Policy and Environmental Changes to Improve Health in Klamath County, Oregon, 43 Changing the Environment to Promote Health Outside the Four Walls of the MD Anderson Cancer Center, 46 Audience Discussion, 49 7 SMALL-GROUP INTERACTIVE EXERCISE: UP/MID/DOWNSTREAM PARADIGMS IN ADVANCING POPULATION HEALTH AND HEALTH EQUITY 53 Instructions, 53 Report Back, 54 8 FINAL REFLECTIONS 57 APPENDIXES A References 61 B Workshop Agenda 63 C Biographical Sketches of Presenters and Moderators 67 D Small-Group Exercise: Up/Mid/Downstream Paradigms in Advancing Population Health and Health Equity 77 PREPUBLICATION COPY—Uncorrected Proofs

Acronyms and Abbreviations AAA Area Agencies on Aging AAMC Association of American Medical Colleges AHA American Hospital Association CBO community-based organization CIL Centers for Independent Living CMMI Center for Medicare & Medicaid Innovation CMS Centers for Medicare & Medicaid Services DRCOG Denver Regional Council of Governments FQHC federally qualified health center IOM Institute of Medicine SIREN Social Interventions Research and Evaluation Network VUMC Vanderbilt University Medical Center WHO World Health Organization WIC Special Supplemental Nutrition Program for Women, Infants, and Children xiii PREPUBLICATION COPY—Uncorrected Proofs

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The Roundtable on Population Health Improvement of the National Academies of Sciences, Engineering, and Medicine hosted a public workshop on September 19, 2019 titled Models for Population Health Improvement by Health Care Systems and Partners: Tensions and Promise on the Path Upstream. The term upstream refers to the higher levels of action to improve health. Medical services act downstream (i.e., at the patient level) in improving population health, while such activities as screening and referring to social and human services (e.g., for housing, food assistance) are situated midstream, and the work of changing laws, policies, and regulations (e.g., toward affordable housing, expanding healthy food access) to improve the community conditions for health represents upstream action.

The workshop explored the growing attention on population health, from health care delivery and health insurance organizations to the social determinants of health and their individual-level manifestation as health-related social needs, such as patients' needs. The workshop showcased collaborative population health improvement efforts, each of which included one or more health systems. This publication summarizes the presentations and discussions from the workshop.

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