Embracing the Whole River Paradigm

Mar 2

Aligning Assets for Mission and Margin

If you work in healthcare, chances are you’re familiar with the health-as-river metaphor where “upstream” health interventions address social determinants of health (SDOH) at the community-level (e.g. good housing for everyone), “midstream” health interventions address individual social needs (e.g. rideshare vouchers and food for those without means), and “downstream” health interventions are medical (i.e. individual clinical care). Historically, the core business of healthcare - a whopping annual $4-plus trillion in the US - has focused downstream. Chronic disease, much of which is preventable and linked to poverty and discrimination (i.e. SDOH), drives as much as 80% of that spending. In recent years, partly spurred by the volume-to-value transition, we have seen increased attention to midstream and upstream interventions; yet the full amount of these investments by healthcare and their impacts is often siloed from the business and not fully known, tracked, or measured.

What is known, tracked, and measured: increasing costs of providing quality clinical care, the challenge of recruiting and retaining an engaged healthcare workforce, and the widening health disparities in communities.

At Multiplier Advisors, we know that future health system performance requires financial sustainability and improved health outcomes for all, and that success is only possible when a health system’s care delivery transformation isn’t happening in isolation. In other words, health systems that embrace the Whole River as core business and align existing assets to address SDOH will advance both margin and mission together.

This blog outlines what we’re calling the Whole River Paradigm, Multiplier’s approach to working with health systems as they deploy assets upstream, midstream, and downstream to improve health and sustain them in their roles as forever institutions - helping systems get more out of what they already spend. The paradigm's approach has three main components: defining outcomes, mapping existing assets, and aligning those assets to the outcomes. We call out examples from health systems who are paving the way, some of which we’ve been lucky enough to support on their journeys.

Define your outcomes

Today health systems are caught in the challenging downstream churn of providing clinical care to an increasingly sick population. Factors such as a constrained workforce, high demand for care, increasing costs, and an ever-complicated cost reimbursement system create dependency on fee-for-service models and concentrated focus on downstream clinical care. Even as systems undertake care transformation - e.g. integrating SDOH screening and referral systems to support patients’ midstream social needs and innovating to improve access and care at reduced costs - their efforts work in isolation from other assets that, if mission-aligned, could work in concert toward the desired outcomes and support the health system’s transition to value.

As a first step, a health system should define the set of high-level, Whole River outcomes it seeks to achieve. By Whole River, we mean that the outcomes should reflect community-level, population-level, and patient-level priorities (upstream, midstream, and downstream) as well as system-level business priorities. We love how Memorial Hermann in Houston, TX describes the nonclinical outcomes it seeks to achieve across equity, community health, anchor initiatives, and environmental sustainability. Notably, the outcomes are as much about the essential business practices (e.g. workforce, hiring, purchasing, and sustainable operations) as they are about their mission to improve health - it is all core to the Memorial Hermann strategy.

Often system mission, vision, and value statements offer good starting points for crystalizing the aspirational outcomes. For example, Nationwide Children’s in Columbus, OH has a set of values that articulate Whole River outcomes, and in a step toward measurement, the health system has published a set of metrics, Pediatric Vital Signs, which they’re tracking in Franklin County, OH to inform how they prioritize and align their assets toward their defined outcome to “measure and improve the health of every child”.

Map your assets

Not surprisingly, in order to achieve Whole River outcomes, a system must deploy assets that focus on interventions throughout the whole river. Most health systems are intentional about tracking and measuring downstream assets and their impact, e.g. specific medical expertise, innovative technologies, state-of-the art facilities and devices, etc. And while some systems have begun to track and publish specific upstream assets that are measurable - we love this report by Hackensack Meridian Health in NJ - in our experience most health systems are spending significantly more on SDOH than they even know. In fact, most of the SDOH spend is invisible and goes unmeasured.

Predominantly, the known upstream work resides in community benefit activities or perhaps as the mandate of a community health or population health team (teams, as you know, that are not often viewed as core to the business). Health systems should consider the much broader range of existing assets they have that can be deployed for impact across the entire system: operating reserves, treasury, hiring and purchasing, real estate portfolios, policy and advocacy strategies, community programs, clinical care, and more.

Adopting an Anchor Mission - committing to local diverse hiring, local diverse procurement, and place-based investing- is a great starting point for identifying assets. Over 70 leading health systems have joined the Healthcare Anchor Network which we see as an important step toward embracing the Whole River Paradigm.

As part of the Anchor Mission or separately, a growing number of health systems have begun to align portions of their operating reserves, endowments, and/or other investment portfolios to mission. Multiplier Advisors, working with our partner Tideline, helps health systems on their impact investing journeys.

Our clients have identified latent dollars in capital budgets that could be invested for impact, advocacy strategies to drive aligned policy change, real estate to leverage for hospital and community impact, and supplier diversity and workforce housing programs that focus on priority outcomes. The point is that health systems have existing assets along the river that, once identified, can be aligned and deployed such that they advance both margin and mission.

And, by the way, when other external stakeholders see health systems involved they often feel more confident about joining in as a partner, amplifying the impact. We’ve been keeping our eye on the exciting example provided by Henry Ford Health headquartered in Detroit, MI. The system is using their land and capital resources to partner with the City of Detroit, Michigan State University, and the Detroit Pistons in the Future of Health - a multi billion dollar mixed-use state-of-the art health, research, and community development project. The project addresses housing, jobs, and healthcare access while embedding anchor principles of local hiring, procuring, and place-based investing.

Align your assets to your outcomes

As a final component, health systems can align their assets to the outcomes they’ve identified, and demand more from their assets so that those assets go beyond their core purpose and advance the health system mission. This alignment process takes intentionality and care, and can require additional focus. For example, Intermountain Health used its Community Health Needs Assessment (CHNA) and a social needs demonstration project to refine its focus on addressing the upstream SDOH that mirrored the highest impact social needs identified by patients, members, and employees: housing and food security. The system then aligned SDOH resources across the organization - impact investments, community health grants, clinics, hospitals, human resources, and their health plan - to address those issues and measure and communicate its impact.

Demanding more from assets gives them additionality - impact that wouldn’t have otherwise been possible. Health systems can think about which assets can do double duty to help address prioritized health disparities and SDOH. Some examples include:

Real estate: Leasing land at a below-market price to community organizations or public entities for the purpose of housing, childcare, or expansion of community services. In doing so, a health system keeps its land for future use or sale while generating revenue and creating community impact along the way. As an alternative to leasing, Stamford Hospital in Stamford, CT swapped land with the local housing authority to create the Vita Wellness District and expand their campus.
Advocacy: A well designed policy and advocacy plan that addresses federal, state, and local policy can ensure a health system focuses its interests on issues central to the health system and offers secondary (or even primary) support alongside key partners around SDOH. Nemours Children’s Health based in Jacksonville, FL provides a compelling example focused on nutrition, education, and more.
Workforce: Hiring from underserved communities (outside in) and creating pipelines for growth (inside up) strategies create necessary new pipelines for employees and increase the likelihood that residents of the health system's service area move out of poverty. ProMedica’s Ebeid Promise in Toledo, OH provides a workforce training pipeline that places residents and students from the Uptown Neighborhood in healthcare jobs at the health system.
Balance sheet: Carving out a portion from the balance sheet for high-impact investments that recycle capital while addressing SDOH in communities has a double bottom line effect. Impact investing addresses SDOH and generates enough financial return to preserve the purchasing power of the allocated capital so that it can be reinvested again and again. Kaiser Permanente’s Thriving Communities Fund currently stands at $400 million committed to investments in housing and economic development. According to KP’s VP of Strategy for Community Health John Vu, “The Fund is central to our mission which is inextricable from our viability as an institution - we are leveraging our assets to create health. With the Fund we are on track to help create or preserve 15,000 affordable housing units by 2025 with the hope of creating or preserving 30,000 units by 2030 while also advancing inclusive economic development.”

The Whole River Paradigm at work

At Multiplier Advisors, we’re inspired by what health systems are doing to embrace the Whole River Paradigm approach. It’s not easy or quick - this blog oversimplifies a process that is often incremental, takes months or even years, and runs concurrent to myriad other health system priorities subject to external variables. A few key ingredients smooth the path:

A firm grounding in the “why” and a long-term view: Having a well-articulated and understood vision for the Whole River can catalyze opportunities to further business and mission priorities together. We hope this blog helps you start to make the case.
Board and C-suite buy-in: Leadership support frees up the resources and time needed to move forward. Integrate knowledge building and education at the beginning of your process to generate that buy-in.
Internal capacity for managing the process: From the internal knowledge building, to alignment, to implementation, it’s critical to have a core team at the forefront shepherding the work. Sometimes it’s one strategically-placed person or a small team, either way an internal champion is a must.

No matter where you are on your Whole River journey, know that even while you’re charting a new course you’re not alone. You have peers who can share learnings from their own journeys, and we’re here to help you all along the way.

Read more about our services on our website, and this spring find us at the Confluence Philanthropy, Mission Investors Exchange, and Grantmakers in Health national conferences.