Leveraging existing resources and strengthening relationships with community-based organizations can lead to "huge ROI" for hospitals, says public health innovator, Rishi Manchanda, MD.
Rishi Manchanda, MD, MPH |
The health care system needs to do a better job identifying and addressing the social, environmental and economic conditions that play into the health of patient communities.
That was the message Rishi Manchanda, MD, MPH, delivered to a group of medical students at Tufts Medical Center in Boston this month. Manchanda is a nationally known advocate of healthcare that looks beyond the clinic and into the lives of the people it serves.
He is the medical director of a clinic for homeless veterans in Los Angeles and founder of Health Begins, a non-profit organization that offers training designed to "equip healthcare professional to design successful upstream solutions to improve care at lower costs."
Building off of his TED talk and subsequent book, The Upstream Doctors, Manchanda contends that the U.S. healthcare system is failing patients by treating disease without addressing the social factors that lead to illness and injury.
He draws the term "upstreamists" from public health parable of three people trying to save children who had fallen into a rushing river. While two of the rescuers work on getting the children to safety, one swims upstream to keep others from falling in.
Citing a study that concluded people who live near green spaces are healthier, Manchanda said he knows the algorithm for when to give a diagnostic test, but "I don't know the algorithm for when to offer a patient a park."
Hospitals as Upstreamists
In an interview after his talk, Marchanda discussed how hospitals can become "upstreamist." The first step is identifying and understanding the social determinants of health: the everyday conditions that amount to risk factors in patients' lives. Then, Manchanda says, the effort is to address these needs and to become more than an add-on or a form of charity. He wants to see the approach formalized, built in to the system and funded.
In his talk, he uses the example of a patient named Veronica whom he treated at clinic in South Central Los Angeles while he was working for the National Health Service Corps. Despite three trips to the emergency room, she had found no relief for her chronic headaches. A medical assistant checked Veronica's vital signs, asked about her symptoms, her care – and about her housing, he said.
Since so many of the clinic's patients live in substandard housing, the staff had learned to screen for health-related risk factors in the home. Veronica was living with three of them—roaches, mold and water leaks.
Manchanda said he walked into the examining room to find the woman doubled over in pain. When she sat up, he noticed an "allergy salute," a mark on the nose from repeated rubbing. He diagnosed her with chronic allergies leading to migraines. And he referred her to a specialist—a public interest housing lawyer.
"I was mad," he said. But, when he went looking for a culprit in Veronica's case, he realized saw that individual providers were "swimming in their lanes, working within the scope of their practices, but collectively, we were coming up short… Somehow collectively, we had provided mediocre care, and when I say 'we,' I include myself. "
'Huge ROI' for Hospitals
Which is what led him upstream. Manchanda thinks hospitals should also look in that direction to improve care. They could begin by leveraging existing resources and strengthening relationships with community based-organizations. Once hospitals begin to identify social factors that influence health, they should screen for them, he says.
"That will yield huge return on investment right away because it demonstrates to the community that the hospital cares," Manchanda says. "It demonstrates that they are data-driven and linking to the needs to the community."
Hospitals already have the tools to address some community-based risk factors through existing quality improvement, electronic medical records and best practice programs, he argues. And with the push for value-based payments, Manchanda thinks there are payers who are eager to sit down and talk to the hospitals about creating a high-value system.
"If we think about the triple aim—lower costs, better quality of care, better population outcomes—I vouch that what we will achieve is a better standard of care, hands down."
The Health Begins website links to a blog post by Doug Wolf, the community health manager at Nationwide Children's Hospital in Columbus, OH, on how hospitals can put upstreamist ideas into actions.
The Patient Protection and Affordable Care Act's community needs assessment requirement puts hospitals in a good position to start making some of the connections Manchanda is talking about, says Wolf. But he thinks hospitals need to avoid taking the standard "needs-based approach" of identifying problems and then creating solutions to fix them.
"We create a client neighborhood where we perceive the people in the neighborhood as clients who need to be served, rather than those who can contribute to solutions," Wolf said in a phone interview.
Instead, he endorses an "assets-based" approach that looks at local residents as resources rather than clients. "These people are closest to the challenges they are facing and have intimate knowledge on how to create a better system," he says.
Manchanda, in his talk, said essentially the same thing: "The biggest thing we are underutilizing is our patients."