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Small-Group Interactive Exercise: Up/Mid/Downstream Paradigms in Advancing Population Health and Health Equity

INSTRUCTIONS

Lourdes Rodriguez of The University of Texas at Austin provided instructions for a small-group interactive exercise. Using the diagram shown in Figure 2-2 describing upstream, midstream, and downstream paradigms in advancing population health and health equity along with other axes for the conversation about addressing health-related social needs, participants were invited to work in small groups to exchange ideas and consider ways to move upstream in ways that are practical for their institutions. Participants also were asked to think about the tensions and promises and cross-cutting themes such as workforce, resources, policy, data, technology, and metrics highlighted in the panel sessions. To guide the conversation, participants were given the worksheet provided in Appendix C, which asks the following questions:

• What information does the diagram seem designed to convey?
• What are its possible uses?
• What changes are needed to make it more useful for specific audiences?
• How does this diagram help describe the role of my organization and work?
• How can I use this in my organization and in my work?
• How can I adapt this to describe my organization and my work?

After about 45 minutes, the workshop audience reconvened and several participants shared highlights from the discussion in which they had participated. These are summarized below. Statements, recommendations, and opinions expressed are those of individual participants and should not be construed as reflecting any group consensus.

REPORT BACK

Reporting on one’s group conversations, Mylynn Tufte of the North Dakota Department of Health shared that many participants found the diagram complete and that it appropriately conveyed cross-collaboration and cross-sector work. Some participants found it particularly useful for illustrating upstream efforts to establish policy, infrastructure, and systems for prevention and public health. They suggested that the diagram could be used to speak with decision makers, propose policies, and advocate for sustained funding. The group suggested that the diagram could be improved by adding columns for cross-sector collaboration and for resource needs. It could also be made more useful by considering the needs of patients, a key group not currently represented.

Other participants noted that the diagram conveys ways that organizations from all sectors could get involved in downstream, midstream, and upstream efforts to advance population health and health equity and move upstream. However, some pointed out that the diagram seemed largely focused on the health care sector. If this is the intended audience, they suggested more explicitly addressing issues in which the health care sector has a unique role to play, such as community benefit, community health improvement planning, anchor institutions, and employee wellness. With respect to intended uses, the group thought the diagram could be useful for helping organizations consider where they currently are with respect to addressing population health and health equity and the path forward. It could also be useful for mapping partners across sectors and for community health improvement planning. Regarding ways to improve the diagram, the group suggested it would be helpful for a future iteration to provide examples of sectors or potential partners in each area. In addition, they noted that some of the language is specific to the health care sector and changes to the terminology or framing could make it more useful for social service agencies or community-based organizations. The list of other relevant sectors could also be expanded to include those beyond health care, public health, education, and housing, such as criminal justice and the environment.

Several participants in another small group found the diagram potentially useful for educating and persuading leaders and decision makers and those outside of public health about strategies for advancing popula-

tion health and health equity. Some suggested ways to make the diagram more useful for audiences outside of the health care sector, including noting the limited financial incentives for moving upstream. They also pointed out that community members and community-based partners such as faith-based entities and human services organizations such as the YMCA are missing from the diagram. Some participants suggested that the figure more clearly distinguishes between the distinct concepts of population health and health equity, the latter of which was perceived to be a component of the former. In addition, some participants underscored the importance of using language and terminology that resonates with the intended audience. To that end, they suggested using the terms thriving or wellness instead of health.

Presenting a last set of perspectives, Alyssa Crawford of Mathematica relayed a need to communicate a strong vision for population health that is not based solely on its history within health care. Some participants suggested that the diagram could be used as a tool for stakeholders and partners to consider the goals of their population health initiatives. The diagram, they added, could better convey the outcomes of population health initiatives and who will benefit from them. In addition, several participants noted that describing only upstream, midstream, and downstream interventions was limiting and did not adequately acknowledge the root causes of the population health challenges the interventions are intended to address, or the root causes of failure of population health efforts, such as lack of clear governance structures, communications, or infrastructure. Specifically, the diagram could better display the interconnectedness between upstream, midstream, and downstream interventions. Crawford also explained that contributors to the discussion suggested conveying incentives and accountability for each action, a suggestion that is especially important when multiple partners are involved. Some participants asserted that a picture, rather than a diagram, may better illustrate the logic model so it is more accessible to a less academic audience.

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