1

Introduction¹

WORKSHOP OBJECTIVES

On September 19, 2019, the Roundtable on Population Health Improvement of the National Academies of Sciences, Engineering, and Medicine hosted a public workshop in Washington, DC, 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. Castrucci and Auerbach (2019) classify medical services as acting downstream in improving population health, while such activities as screening and referring to social and human services are situated midstream, and the work of changing laws, policies, and regulations to improve the community conditions for health represents upstream action.

The workshop was organized by an ad hoc planning committee to discuss the growing attention to 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’ need for transportation and housing. The charge to the planning committee is provided in Box 1-1. The workshop showcased collaborative population health improvement efforts, each of which included one or more health systems. The leadership role was not always held by a health system; in some cases, it was shared with, or held by, a public health agency, human or social services agency, or community organization.

Sanne Magnan of the HealthPartners Institute stated in her opening remarks that the Roundtable on Population Health Improvement

provides a trusted venue for leaders in the public and private sectors to meet and discuss the tensions as well as leverage points and opportunities arising from changes in the social and political environment for achieving population health. The roundtable vision is of a

Magnan informed the audience that the Health and Medicine Division of the National Academies conducted two other activities related to the topic of the workshop on addressing nonmedical but health-related social needs and social determinants of health. A Proceedings of a Workshop is available from an April 2019 workshop titled Investing in Interventions That Address the Nonmedical, Health-Related Social Needs (NASEM, 2019b). A consensus study report titled Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the

Nation’s Health (NASEM, 2019a) was released in September 2019 following the workshop.²

The focus of this workshop, Magnan stated, would be on the evolving efforts to respond to health-related social needs in a manner that is increasingly oriented upstream (e.g., policy change) and not limited to efforts that are somewhat more downstream, namely clinic-based and individual-level interventions (e.g., behavior change). The efforts to be highlighted in the workshop also are informed by community wisdom and by learning from partners, including and especially those from outside the health system. Throughout the workshop, speakers and panelists highlighted the interwoven efforts of health systems and their many partners to move beyond what takes place in clinical settings and to collaboratively identify and respond to the needs of patients and communities.

Magnan concluded her remarks with thanks to the planning committee, which, in addition to herself, included Philip Alberti of the Association of American Medical Colleges, Marc Gourevitch of New York University Langone Health, Sally Kraft of Dartmouth-Hitchcock, Jeff Levi of The George Washington University, Rahul Rajkumar of Blue Cross and Blue Shield of North Carolina, and Lourdes Rodriguez of The University of Texas at Austin. The charge to the planning committee is provided in Box 1-1.

ORGANIZATION OF THE WORKSHOP AND PROCEEDINGS

The workshop featured two keynote presentations (see Chapter 2) providing an overview of some of the landscape of population health improvement efforts from the perspective of health systems, including the “tensions and promise” mentioned in the workshop title. Four panel sessions and discussions followed, primarily from a health systems perspective. Programs and partnerships that were showcased focused on expanding midstream and upstream approaches to population health improvement. In Chapter 3, the first panel focused on how leadership and organizational structure can support addressing health-related social needs and advance health equity. In Chapter 4, the second panel focused on a health system and community partnership. In Chapter 5, the third panel featured a model for a health-sector partnership with a human services organization. In Chapter 6, the final panel explored changing systems and changing policy (e.g., tobacco laws). A small-group interactive exercise examining upstream, midstream, and downstream paradigms in

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² That committee’s report, Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health, was released on September 25, 2019, and is available for free download at https://www.nap.edu/25467 (accessed May 28, 2021).

advancing population health and health equity is described in Chapter 7. The workshop concluded with reflections on the workshop’s presentations and discussions in Chapter 8.

A METAPHOR FOR FRAMING THE WORKSHOP

In his reflections at the close of the workshop, Bobby Milstein of ReThink Health shared a colleague’s quote that “health care is a planet that thinks of itself as the sun.” The speakers, Milstein asserted, illustrated a new standard for how health care institutions are working to reposition the systems that thought of themselves as the center of the universe, and that have been resourced accordingly. The workshop, he added, shares stories of how varied leaders are “marrying” health system efforts and the existing, longstanding community infrastructure of human services and other organizations.