Dr. Rishi Manchanda is President and CEO of HealthBegins, a mission-driven consulting and technology firm that helps healthcare and community partners improve care and the social factors that make people sick in the first place. His career is marked by a commitment to improving care and social determinants of health for vulnerable populations. He served as director of social medicine for a network of community health centers in south central Los Angeles, was the lead physician for homeless Veterans at the Greater Los Angeles VA, and was the first chief medical officer for a self-insured employer with a large rural immigrant workforce. In his 2013 TEDbook, The Upstream Doctors, Manchanda introduced a new model of healthcare workers — the Upstreamists — who improve care and equity by addressing patients’ social needs, like food, financial and housing insecurity. The book has become recommended reading in medical schools and universities across the world.

Barilla: Hello everyone and welcome to Next Generation Community Health with Providence St. Joseph Health. I’m your host, Dora Barilla. Today we’re joined by Dr. Rishi Manchanda, the president of HealthBegins, and we’ll be talking about the Power of Moving Upstream and what that means and Rishi is probably one of the best physicians in the country to have this conversation, so we’re really privileged to have you here. Thank you for being a part of our conversation.

Manchanda: Thank you, Dora.

Barilla: So let me start with upstream, the term. We’re hearing more and more in corporate speak, but I’m not sure everyone understands it. Can you help us define what upstream means and how does that relate to social determinants of health?

Manchanda: Thanks Doris. First of all, thank you for also this. This is going to be a fun conversation because it’s not often that we have a chance to sit back and talk about these issues, especially these days when so many of us are actually doing the work of moving upstream. But what do we mean by upstream? I use a parable and I think a lot of folks understand to be able to really bring this home.

So the parable is the story of three friends. Three friends who come to a scene, a river with a beautiful… the birds are chirping, sun is out. But something is tragic about what they see. They see people in the water. These three friends see that there are children, the elderly, adults of all ages in the water, and they’re not leisurely swimming, they’re actually drowning. And so three friends do what all of us do, they jump in to help.

The first friend says, “I’m a strong swimmer. I’m going to save those who are about to drown,” and goes to the edge of the waterfall that maybe there just to make sure that those who are in need of rescue, get rescued. The rest of us now who have amassed along the banks of the river applaud that. Makes sense, let’s give that person as many resources and love as possible because it’s noble necessary work.

The second friend over time says, “You know, I have an idea. I’m going to coordinate the branches along the banks of the river and build a raft and usher people to safety”.  Let’s call it a patient center medical home, while we’re at it. It’s essentially a primary care. Let’s prevent people from ending up in need of downstream rescue all the time. And so the second friend and the first friend, now the rescuer and the raft builder are working and humming along and they’re doing noble necessary work. Sometimes they’re getting a little burned out though, because they realize that the tide of need continues, unabated. Sometimes recognize the same people they just rescued the day before back in the water again and they start getting a little fatigued, because they realize something is really fundamentally wrong. And then their frustration gets compounded by their sense of exasperation.

When they realize that their third friend is nowhere to be seen. And the way I tell the story, that the third friend, they finally spot her and she’s in the water, she’s swimming upstream. It’s usually a woman who’s the smarter one in this kind of story, who’s realizing that there is a slightly different kind of role here to play to support the rescuer and the raft builder. And what these two friends realize is that she’s swimming away from them upstream and they shout to her, “Where are you going, they’re people her to save.” And the third friend, she’s swimming upstream and she’s saving lives as she’s going, she’s doing the work. She shouts back, “I know, I’m going to find out who or what is throwing these people in the water.”

The upstream parable, when we talk about moving upstream, it means really understanding the who, the what, the structures, that are putting people into this river, towards ill health, towards poor outcomes, preventable diseases, etc. And so far, in our healthcare system, most of us have been used to operating the model that it’s about the rescuers and the raft builders. Specialists, trauma surgeons, ICU nurses; and then the raft builders, the primary care teams. That model is only two thirds right. We have to think about including a version, story of ourselves I think about the upstream structural issues, the social determinants of health and that’s what we mean by upstream. I think generally most folks in healthcare now who are using that term are essentially using it to speak about those social needs. I tell it in the form of that parable so they can just feel more. We can understand it in our bones rather than just in our minds.

Barilla: Well thank you for sharing, such a great story to really highlight what that means. But that really leads me to… share with our listeners, as a medical doctor, how did you become so interested in working upstream? Weren’t you trained to address the medical homes and those at rescue. So what was the shift?

Manchanda: Yeah, why is a doctor talking about upstream stuff, didn’t I train as a downstream person? It’s a great question and it’s not a surprising question. Because of what we consider to be what is the purview of healthcare and what is the purview of public health. We’ve viewed these as two different domains. I actually think that’s to the detriment of the shared goals that we have, which is to improve health, whether it’s the individual level or for communities. So why it’s important for me is because I know that as doctor, as a caregiver, as a professional caregiver my job is to provide the best quality care to achieve the best possible outcomes at the lowest possible costs, right for my patients.

Every time I’ve tried to do that in a variety of different settings, especially with populations of and communities where the need has been sometimes disproportionately higher, underserved communities.

Every time I’ve tried to do that to be that type of doctor, I’ve had to necessarily understand upstream issues.  It’s hard to have a conversation with a patient who is a diabetic and you say, well here’s your insulin. Again, because I’m a doctor, I’m trained to give you the treatment you need, and then not be able to understand what to say in response when that patient says, well, I don’t have a fridge to store it in.

It is unsatisfying professionally as a doctor to not have an answer for that. And it doesn’t mean that, we as doctors, become public health professionals, community health workers, social workers, transportation experts or anything else. It does however mean that if I’m going to be a really effective doctor, I have to understand how to coordinate with those other folks and do so with the same rigor as I would with a cardiologist or with another specialist in the clinical field.

I still find it surprising sometimes that they’re folks out there in the public health community and even medicine who say, “Well this is not our job” and I challenge that fundamentally. I think that anything less than an upstream context or understanding in healthcare is substandard care. Patients deserve the best quality care and a model of care that doesn’t include an understanding of how to help work with partners in the community to address their upstream needs is substandard, and I didn’t sign up for that as a doctor. So, that’s why I do it to be a good healthcare provider.

Barilla: Well I have to interject, as a doctor of public health, amen, because you’re absolutely right. We have to have that partnership in really addressing that, so that’s really a refreshing viewpoint.

So tell us, what are going to be the necessary paradigm shifts in the healthcare industry to successfully address completing this work?

Manchanda: Yeah, so we think about this a lot. We’ve had conversations about this and I think we’ve all probably, for those that are listening in, all of these conversation about is what we’re doing enough? Is there a need for a shift in the paradigm and the way of thinking?

So paradigm is a pretty heavy term, right? One way I try to unpack it is to understand that it’s just a mental model. If you use that term I think in ways that help me to understand, what we mean by paradigm.

So a mental model it really is, is it what you consider to be usual, what’s possible, what is doable and what’s not. A mental model that says moving upstream is now possible or maybe something we should try, is a paradigm shift. It’s one that’s very different from a mental model that says, “No, that’s not my job.” Our job is not to think about or addressing upstream.

So I think we’ve already made a little bit of a shift in the paradigm in having healthcare systems now start these days more than ever before, start thinking about social determinants of health.

I think the next wave, if we’re going to fully do the shift, is to move past the model where we’re essentially assuming that we can be the same people that we are now when we try to move upstream.

In other words, as anybody knows, when you swim upstream, when you take on any activity, and imagine actually, going back to that parable, you’re that person now swimming upstream. By virtue of actually doing that work of navigating uncharted territory, of meeting new partners, meeting new people, of swimming in a stream against the tide sometimes as it may feel like. When you’re doing that work, you are changed by it. Everybody talks about a trip they take and how the travel changes them. They are a different person now because that experience has made them different. This is exactly what will happen with being part of this upstream movement.

The paradigm shift I think we need to now start to wrap our head around is how to really fully recognize that. We can’t and shouldn’t expect to be the same type of organization at the end of this journey upstream or in the process of moving upstream that we are now; that we will change. And that’s a good thing. We should embrace that. And we should do the same when we’re partners in the community, right? This means changing relationships.

The way I like to talk about it sometimes to bring it home. When I got married I went through a process of recognizing, and it really … sometimes it was harder than I like to admit, but when I got married I was like, great, I get to show up as who I am and my wife will do the same thing on her side and we’ll show in our new entity. That was not the case, right?

When we had to negotiate where the toothbrush would go. As we were dating, got married, understanding each other’s personalities and quirks and whims, we changed as individuals. The very nature of being in a relationship changed the people in the relationship.

Same thing for partnerships. When hospitals work with food banks or housing agencies work with health plans. We can’t expect ourselves to be the same people and when we enter these relationships, we are going to be changed because of it. And so one question is, do we have our eyes wide open about that and embrace that relationship and the fact that we’re going to change because of it and try to figure out ways to optimize the relationship, to make it work, make that marriage work, or are we going to be blind to the fact that this doesn’t require change, are we going to assume that we’re the same people, the same organization going in and that we’ll come out the same way.

We are going to change and we should change and in fact I think the paradigm shift is that … the exciting part in the paradigm shift is saying, “Can we change in incredible necessary ways that our patients and our communities require?”

Barilla: So really adding on that, you talked earlier about the roles and relationships with physicians and those that are doing a lot of community health work, but talk a little bit about are there new roles that we might need to think about in our systems, or do they exist, do we just transform how we’re thinking about them, or do we need to create new roles to make this successful in our healthcare systems and in our communities?

Manchanda: Yeah, so roles can be only considered, in my mind, as a function of functions. What functions do we need to achieve? So do we need to work differently to be able to address food and security for a population of diabetics in a certain geography? Do we need to think about new ways of financing interventions so we can avoid the… phenomenon? Whatever that objective is as part of this moving upstream, whether it’s around financing or data or programs, the functions that are required to achieve that objective, are the first kind of question. What are the functions? Then if we actually map those function, we can step back and say now what roles do we need to play to be able to achieve those functions to implement that change?

I think there’s essentially three ways of them thinking about the types of roles. There’s three answers to that question. One is, in our existing work, in our existing roles, how do we operate in this in a way that doesn’t require us to change too much? Can, for instance, our team of data scientists or our finance team or our quality improvement committee just show up as they are right now and play that role to support this. So now that same group is now aligned with that objective. No change in roles, existing roles stay the same but now they are aligned with that objective.

The second type of role is, all right, well can existing folks then be repurposed? Right, and so at the level of care teams for instance. In clinics there is a lot of folks saying well maybe we can work with medical assistants. And even though five years ago screening for social needs wasn’t part of the usual job description for medical assistant. Maybe we can repurpose that same staff role and apply them for this purpose. So there’s a lot of repurposing, so it’s the same people but now adding a new dimension to their work. And that’s not too unusual. We’ve done this before with behavioral health for instance. Twenty years ago screening for depression wasn’t standard practice in a lot of clinic settings but now it is. We can always change roles; we always do it.

The third thing is actually, probably the most challenging thing is are there new, beyond the existing kind of teams, existing roles that can be repurposed; is there also new people, new team members and that’s usually the most difficult thing for people to wrap their head around. Do we need to a new staff person like a community health worker to achieve functions that our existing resources can’t do? What unique things about a community health worker or a promotoraare necessary? Do we need a lawyer on the team, right in a medical legal partnership kind of model, because that’s how we’re going to achieve our objective? Do we need a finance person to join our quality improvement committee to make sure that we’re actually penciling out the ROI for our upstream quality improvement initiative?

Whatever it is, I think that’s the most difficult part for some folks. We don’t recognize sometimes that it’s not just about taking existing resources or teams or repurposing existing resources, this is about identifying new roles. I think those are the three categories and then for each person in those roles, the question is where are you going to lead, where are you going to partner, and where are you going to support? And answering those questions I think can accelerate our progress to get some more rigor in us.

Barilla: That’s a really great way of looking at the structures of how we go forward with this work. I like that. So you talked about food banks and homeless shelters. Those aren’t usually the traditional partners that healthcare providers usually think about. Are there other partnerships that, in addition, you mentioned legal, other partnerships that we’re going to have to be thinking about in terms of how we move forward with addressing a lot of social issues?

Manchanda: I think the answer is yes. There’s a lot of potential partnerships and resources that are out there. I think we can learn a lot from the initial partners that we’re starting to work with from the healthcare perspective. We’re seeing more hospitals and health systems working with food banks and working with, especially in the Food-as-medicine coalitions that are merging around medically tailored meals for patients with certain conditions that clearly need and benefit from medically tailored meals like people with congestive heart failure or really severe complex diabetes or kidney disease.

So we’re seeing work in partners in the food security space. We are also seeing of course housing, permanent supportive housing, rapid rehousing, the whole spectrum of housing work. And it’s something to be said for the fact that while those partners in those domains are, we’re still kind of in early stages of developing and making those partnerships really robust, there’s something to be said for what we can learn from those two sectors and why we are partnering with those two and not necessarily others, yet, and maybe we can start being more rigorous.

So why is it that we’re talking about food and transportation and housing? Mostly it’s because their services from those sectors tend to align more easily. It’s not easy, but they align more easily relative to others with the budget cycle and the kind of cultural norms of healthcare. We work on one-year budget cycles; we need ROI sometimes that happens in that time cycle. Well, feeding somebody, getting somebody housed and getting somebody a ride generally tends to produce, at least some early wins. That can happen in the time cycles that we in healthcare understand, and…respond to.

But it’s not the same for early childhood education or for other kind of demands. Like for instance, criminal justice advocacy organizations or others. So I guess the question for us now is, as we think about other partners, one question is who’s not in the room, besides food, housing and transportation, are there other sectors, and the answer to that is yes. We should bring in criminal justice partners, we should bring in folks I think in the childhood development and the social connector organizations that are out there: the folks who actually provide, not just children, but the elderly and everybody in between, connections to each other; the Big Brothers Big Sisters groups, the YMCA’s the YWCA’s of the world, who actually provide that kind of community approach. Those are the new partners that we’re going to see. I think we’re going to see partnerships even more with police departments in some regions where there’s a good partnership, a good culture of engagements between the healthcare systems and the police departments because we’re going to see partnerships with paramedics. These partnerships are going to start to emerge especially if we’re able to identify how to take our budget time cycles and see how we can align with their services, their specialties.

The one area that I think we still haven’t really touched yet but I think might happen in the next five years is the way in which healthcare systems are able to partner with advocacy organizations, not just service organizations. We’re not there yet, but we can get there, especially with their kind of rigor that’s required in moving upstream, but I think not all these questions are going to be served away, right?

Barilla: Yeah, absolutely.

Manchanda: And so how do we in healthcare now start to with rigor, partner with organizations that provide advocacy and do other things that are outside of just providing services?

Barilla: Such a good point. I would say the future is here, it’s just not equally distributed. If you think about all of the communities and all the systems that you’ve worked with, can you maybe share an example or where some really great things are happening?

Manchanda: Well certain example within Providence of St. Joe family, and this is obviously shameless plug for the work we’re doing together, working with some of these regions and the privilege that it’s afforded me is the ability to meet some of these systems across the seven states. The Providence of St. Joseph is working in right now to be able to understand the diversity of social determinants that are being addressed from both the community investment side, the population health teams and Medicaid strategies. All these things are coming together. So in that experience, I think about some of the work right now in Orange County around housing, that’s coming together. There’s such a robust network of organizations coming together in Orange County around permanent supportive housing options and other housing options for chronically homeless. Providence St. Joe’s is now with multiple aspects of the system from the community benefit/investment side as well as the population health side and the hospitals themselves thinking about how they can play a role, where they lead, where they can partner and support in that ecosystem.

And it’s phenomenal thinking about the jamboree work and some of these other examples that are happening there. That story among many of the others I’ve been learning about in the Providence of St. Joe’s experience gives me a lot of hope that … it’s so great to see a lot of folks with really, not just great talent, but good will, in the healthcare side who have been thinking about this for a long time. This is not the first time they’re thinking about social determinants, but now they’re realizing this is an opportunity to act on it. And they’re ready and willing and able to do this work now that … and so the question is, how do they most effectively do that with their community partners. So it’s really invigorating to hear that.

There are hospitals and health systems in other parts of the country right now where similar things are happening. Some folks are focusing in on looking at the structural and institutional changes. I think that’s an interesting kind of domain. How do we not just look at how to optimize and reimagine what it means to provide individual care with upstream sensibilities? There’s an opportunity now to think of, and I’ve seen some examples of hospitals that are looking at what they’re doing institutionally. So for instance, instead of just screening for food insecurity among our patients, can we screen for it among our employees?

Barilla: Yeah, absolutely.

Manchanda: Because in some health systems like that, the very people that work with us, they work for us and our colleagues, our loved ones and our family at work, are from the same communities that we’re trying to serve. And that may be a blind spot right now that we have institutionally. So I think that’s another aspect of the change that happens when you move upstream, the kind of realization that wait, this means we may have to actually look inwards in ways that we haven’t really done before around these social needs. And that’s exciting, its challenging, but it’s exciting work to consider that too. So I get jazzed about that too looking at not just the outward work that’s happening for communities and patients, but the inward-facing changes that are happening as institutions start to realize maybe we can start looking at social determinants within.

Barilla: I really love your idea of hope and as we think about the future. Share a little bit about what’s your vision for the future to come in this field?

Manchanda: I have been thinking about this for a while and I’m still grappling with it. But I’ll tell you where my current thing is about the future could look like and this is a … it’s a set of questions that are filled in parts with a sense of hope but also a sense of pensiveness. Are we doing enough, are we doing everything? I come back to my core operating principals, the operating system, the IOS of Rishi. My IOS is driven by five guiding principles. My sense of privilege.

A long way of answering your question, Dora, but I think that in terms of what the vision looks like, I try to understand what privilege means for me and for HealthBegins and especially working with our partners. By essentially saying that there are five different types of people in the world. There are those who don’t have privilege and are aware of it. There are those who have privilege and are unaware of it. There are those who have privilege are aware of it and really love all the trappings that comes with, I love the accoutrements privilege are addicted to it, give me more please, I want more privilege. Then there is the fourth category of people that have privilege are aware of it but actually are paralyzed by it. Oh my goodness, what are we going to do about poverty, I’m not sure, and they end up, well let’s go get a latte, it’s too overwhelming, they get paralyzed by the awareness of this, I’m not sure how to act.

And then there is the last category of folks who have privilege are aware of it and are always trying to figure out how to apply it for good. And by good, I’ll unpack that in a second. The first point is that the reality is actually that there is not five different types of people, in turns out each one of us, I think, in my IOS, we have elements of each of those five types in ourselves. Each of us has parts of we’re not aware of… we don’t have privilege, we are aware of the lack and where on the other side of the spectrum too, where we recognize that we have some privilege and we’re trying to think about how to apply it for good. And then some of us, we get paralyzed by the privilege, etc.

For me, the question is how can I always make sure individually that I’m operating in that last category, that the majority of my kind of mind and work and soul is in that last category of being aware of privilege and always thinking about how I can leverage it for good and not be unaware, the unwoke, phase.

The reason this is important is because when we think about the future, to answer your question of what my vision is, I think for me what that means is playing as much of a role as possible with the people I love and work with, every day, the partners, the team at HealthBegins, others that we get to interact with. How can we actually spend the majority of our time actually in that last space? Always recognizing our privilege right now and always thinking about how to apply it for good?

So when we are working right with Providence St. Joe’s, there is incredible and necessary and hard work right now, working with regions, helping them to understand the social determinant metrics, etc. But there is also this deeper question, are we leveraging our position and privilege for as much good as we can get done. That intentionality I think is what I hope to have more of five years from now where the majority of health systems that are moving upstream are not only showing great impacts with demonstrable improvements in outcomes for patients and saying “Because we moved upstream we improved people’s lives and communities,” but they’re also showing how they actually started to actually recognize privilege in a way that was not just about individual privilege, but institutional privilege and structural privilege. Because we in healthcare have enormous privilege. We have resources relative to our social sector brethren. There is so many organizations out there that would kill for a scrap of our margin in healthcare. So we have the responsibility to actually understand our privilege and then be able to think about how to leverage it for good, always.

And that’s why the community investment work that you’re doing and the conversations I get to engage in every day is incredible to be a part of this because it’s working with people who are thinking about not just how to do good work, but then how to leverage their position of privilege to do even better, right and change structures.

And I think the future… has to be about increasing the number of people who are engaged in that kind of work. So that’s my hope, that more of us are just woke. And awoke in terms of not just structural racism and sexism and these other kind of issues, but also awoke to the sense of what we can do individually, institutionally and structurally to be able to leverage our position of privilege for good. Doing this upstream work in and of itself, is meaningful, but doing upstream work in that context, I think would be a life well lived.

Barilla: Well I don’t know if you could really top those for last words, Rishi, but going to give you the opportunity. Is there anything you’d like to leave with our listeners today?

Manchanda: Well the last thing is, this is really fun.

Barilla: It is.

Manchanda: Like this work is, it can pretty deep and heavy especially when I go in to talk about like life well lived and stuff like that.

Barilla: Absolutely.

Manchanda: This is fun stuff and one incredible time to be alive and working on these kinds of issues, right where we’re thinking about how to move upstream, we’re thinking about … we’re actually doing the work as well not just thinking about it now. What an incredible opportunity to not just do that but then to have this amount of fun, it should be illegal. It’s so invigorating to think about how to move upstream these days more than ever before. Yeah, it’s fun.

Barilla: Definitely a privilege to be living in the space of your passion so, well thank you so much for joining us today Rishi because it is a lot of fun. We’d just like to thank you for joining us today and everyone for listening and we look forward to our next topic with our podcast and to another partner that is really living out Rishi’s future in vision and living into the space of how do we improve the communities and the health of the communities that we all live in. So, thank you.

Listen to Rishi Manchanda’s TED Talk, CLICK HERE.