Checklist to move your healthcare upstream

(Adapted from the The Upstream Doctors)

Healthcare can be better when all of us, including our doctors and nurses, have the right tools and support to fix the upstream causes of illness in our lives. That’s why the future of health care depends on growing and supporting more “upstreamists.” These are the rare innovators on the front lines of health care who see that health (like sickness) is more than a chemical equation that can be balanced with pills and procedures administered within clinic walls.

Upstreamist practitioners — who may be doctors, nurses, other clinicians or community health workers — know that asthma can start in the air around us. They understand that obesity, diabetes, and heart disease partly originate in our busy modern schedules, in the unnatural food choices available in our communities, and even in the way our neighborhoods are designed. They know that ailments such as depression, anxiety, and high blood pressure can arise from chronically stressful conditions at work and home. They see how policies that afford or deny opportunity, fairness, and justice can be reflected in their patients’ faces as well as in their DNA. And, just as important, these caregivers understand how to translate this knowledge into meaningful action by helping to transform the way clinics and hospitals care for patients. The upstreamist considers it her professional duty not only to prescribe a chemical remedy but also to tackle sickness at its source.

There aren’t nearly enough of these pioneers working in health care today, but their ranks are slowly growing thanks to HealthBegins and others who train and support Upstreamists. And you, in small ways every day, can support Upstreamists. Here are six ways to start moving your own health care upstream.

1. Identify risks in your home, workplace, school or community
Create a list of questions or concerns about potentially unhealthy issues in your environment. Think of visible, known problems as well as the absence of healthier alternatives. List as many concerns as possible. Then categorize your concerns based on location: home, workplace, school, community, and society.

For example:
Home: Faulty wiring in guest room; water leaks in basement; too many processed, carbohydrate-rich foods in pantry; household budget runs low at end of month, driving unhealthy choices
Workplace: Donuts served at office meetings instead of healthier snacks; no walking path around office; high stress/not enough social support at work
School: Unhealthy school lunch options; not enough trees or plants; recess shortened by testing requirements
Community: Need a speed bump on a local street where pedestrian accidents are common; not enough green spaces for everyone; not enough child care or elder care options; more fast food restaurants than affordable farmers markets
Society: housing or employment policies create unfair barriers or burdens for some populations more than others; too little invested in prevention and public health.

Some of these problems you might be able to fix yourself. For the others, work with a local group of neighbors or consult relevant professionals or public health agencies. The rest of this checklist offers different avenues to work with your healthcare provider to address your upstream concerns.

2. “Excuse me, Doctor. Are you an upstreamist?”

There’s a reason why billions of dollars are spent each year by pharmaceutical and medical device companies on marketing that urges us to “ask your doctor about [insert brand-name drug or procedure here].” Because it works. Millions of people walk into their doctors’ offices and ask about advertised products. And evidence demonstrates that this significantly influences doctors’ prescribing, even though doctors often believe they’re immune to it. That’s nothing to celebrate. But we can still deploy the same tactic to engage more clinicians in thinking about creating a better standard of care that improves health where it begins, outside the walls of the exam room.

So, next time you visit your healthcare provider, ask them “Are you an upstreamist?”
Bring your list of concerns about upstream issues (see Step 1). Explain your own understanding of the ways in which your health begins where you live, work, eat, and play. This can provide your healthcare provider with valuable contextual information about you, and help improve the care you receive.

3. Share information about you and your community with your clinician

A surprisingly small number of healthcare providers have up-to-date information about local resources or social services that can help patients in times of need. You can help by sharing information about community resources with your clinic. Don’t underestimate the value of your own knowledge about local resources for healthy living. Is there a favorite park, walking trail, or exercise program you use? Do you know about a great farmers market or a helpful lawyer open to pro bono work? Tell your healthcare provider. She and her colleagues can share that knowledge with other patients who may benefit.

If you’re a data geek or love gadgets, consider other ways of sharing upstream information. More and more, everyday folks are downloading mobile apps and donning wearable sensors to collect data on aspects of their daily lives (such as air quality, diet, and exercise). The new “quantified self” technologies present an opportunity for consumers to support an upstreamist approach in medicine. If you’re motivated to discover patterns in your health behaviors and environment, download one of many available apps. Then share your discoveries with your healthcare providers; ask them to help you interpret your personal data, and understand the link between your health and the way you interact with your environment.

If you’re active in your neighborhood, consider aggregating data from a group to form a “quantified community” and share your insights with local public health workers to help them spot common health problems or social needs that demand intervention.

4. Rate your health care
Every hospital and clinic is routinely audited on a host of measures — details that get right down to the cleanliness of exam rooms, adequate stocks of medication, and patient satisfaction.
You can conduct your own assessment. Here are a few basic questions you can use to rate the upstreamist performance of your doctor, clinic, and hospital, and to encourage them to understand health where it begins. Share your results with neighbors and your city or county health department. Let your health plan, employer, and union know that you’re interested, as a consumer, in using these measures to evaluate providers in your plan’s network.

Does your clinic or hospital:
• Regularly identify the health-related social and environmental needs of the community it serves?
• Have a dedicated person or team working to address the social conditions that make people sick?
• Routinely screen patients for risk factors in their homes, workplaces, and community?
• Routinely connect patients with social and environmental needs to resources in the community?
• Go beyond the level of the individual patient and help improve social and environmental conditions in the community?
• Reflect an upstreamist approach in the way work is financed? (e.g. do they have community health workers on staff? Are clinicians paid a salary, instead of reimbursing them based on the number of services delivered?)

5. Vote with your feet
If you ask local clinics these kinds of questions, you may find that the highest-scoring clinics also seem to offer the best quality, most personal care. Upstream-oriented clinics employ people who work to understand and improve health in its social context – which means they might just figure out that your migraines are due to the mold in your home, and then find you a housing professional instead of dosing you up with ineffective pain pills. If you’re looking to change doctors, vote with your feet – and your health care dollars — for an upstreamist clinic. Tell your friends about the clinic and encourage them to check it out for themselves.

6. Vote with, well, your vote
Officials in town halls and city council chambers across the country make policy decisions every day that affect the landscape of health in our communities. Health implications crop up in places that might surprise you: transportation issues are seen only as transportation issues, and building codes only as building codes, but they can profoundly influence a community’s wellness. Support increased investments in sensible upstream public health, prevention and social service programs and initiatives. Ask your local officials to use health impact assessments, a new tool modeled on environmental impact assessments, to inform policy decisions that might seem, on the surface, unrelated to health. Or to follow California’s lead – the state created a Health in All Policies initiative to factor health into a wide swath of state decisions.

Evidence suggests that communities with higher civic participation rates tend to be healthier. In your own neighborhood, you can join or lead efforts to maintain safe parks and walkable sidewalks, expand healthy food options, and limit pollution. Make sure these efforts are fair and improve opportunities for health for the most marginalized members of your community. If your clinic or hospital has a community advisory board, consider joining it. If one doesn’t exist, consider starting one. Finally, you can help by supporting efforts to provide nonpartisan voter registration services in your area, including your doctor’s office (Why not? After all, if you can register to vote while you wait at the DMV, why not have the same opportunity at your doctor’s office?).

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