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1 Introduction1 WORKSHOP OBJECTIVES On September 19, 2019, the Roundtable on Population Health Improve- ment 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 situ- ated midstream, and the work of changing laws, policies, and regulations to improve the community conditions for health represents upstream action. The workshop was organized and convened by an ad hoc plan- ning committee to discuss 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 patientsâ 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 leader- ship role was not always held by a health system; in some cases, it was shared with, or held by, a public health agency, a human or social services agency, or community organization. Sanne Magnan of the HealthPartners Institute stated in her open- ing remarks that the Roundtable on Population Health Improvement 1 PREPUBLICATION COPYâUncorrected Proofs
2 MODELS FOR POPULATION HEALTH IMPROVEMENT BOX 1-1 Workshop Statement of Task An ad hoc planning committee will organize and convene a 1-day public workshop to discuss the growing attention from health care delivery and health insurance organizations to the social determinants of health. Trends and exam- ples regarding health system engagement in population health ranging from i Ândividual-level patient management efforts that focus on individual-level patient social needs and âmedicalizeâ population healtha to more community-level inter- ventions will be explored and discussed. The workshop will also present exam- ples of innovative health system efforts that are focused on upstream (meso and macro) level factors, and will discuss the challenges and benefits of promoting upstream (i.e., population-level, systems, and policy-focused) approaches to population health and health equity, including the community-level infrastructure needed to support more upstream efforts. A proceedings of the presentations and discussions at the workshop will be prepared by designated rapporteurs in accordance with institutional guidelines. a Medicalization of population health generally refers to an overly clinical or medical a Â pproach to improving health or a focus on clinical solutions at the expense of or with disregard for what evidence shows are the real factors that shape health. Lantz (2019) and Woolf (2019) offer two perspectives on medicalization, and the topic is discussed in NASEM (2019a, p. 127). 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 strong, healthful, and productive society that cultivates equal opportu- nity and human capital, and rests on the recognition that outcomes such as improved life expectancy, quality of life, and health for all are shaped by interdependent social, economic, environmental, genetic, behavioral, and health care factors, and will require robust national and community- based actions and dependable resources to achieve it. Magnan informed the audience that the Health and Medicine Divi- sion 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 Work- shop is available from an April 2019 workshop titled Investing in Inter- ventions That Address the Nonmedical, Health-Related Social Needs (NASEM, 2019b). A consensus study report titled Integrating Social Care PREPUBLICATION COPYâUncorrected Proofs
INTRODUCTION 3 into the Delivery of Health Care (NASEM, 2019a) released in September 2019 following the workshop.2 The focus of this workshop, Magnan stated, would be on the evolv- ing 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 out- side the health system. Throughout the workshop, speakers and panelists highlighted the interwoven efforts of health systems and their many part- ners to move beyond what takes place in clinical settings and to collab- oratively identify and respond to the needs of patients and communities. Magnan concluded her remarks with thanks to the planning commit- tee, which, in addition to herself, included Philip Alberti of the Associa- tion of American Medical Colleges, Marc Gourevitch of New York Uni- versity 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 âtensions and promiseâ mentioned in the workshop title. Four panel sessions and discussions followed, primarily from a health systems per- spective. 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 sys- tems and changing policy (e.g., tobacco laws). A small-group interactive exercise examining upstream, midstream, and downstream paradigms in 2 That committeeâs report, Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nationâs Health, was released on September 25, 2019, and is available for free download at https://www.nap.edu/25467 (accessed November 25, 2019). PREPUBLICATION COPYâUncorrected Proofs
4 MODELS FOR POPULATION HEALTH IMPROVEMENT advancing population health and health equity is described in Chapter 7. The workshop concluded with reflections on the workshopâs presenta- tions 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 colleagueâs quote that âhealth care is a planet that thinks of itself as the sun.â 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 âmarryingâ health system efforts and the existing, longstanding infrastructure in communities of human services and other organizations. PREPUBLICATION COPYâUncorrected Proofs