Peer insights: Exploring a coordinated person-centered approach to human services

Imagine Sarah is a 37-year-old woman who has difficulty keeping a job, because of time off due to not feeling well. After being rushed to the hospital after collapsing on the street, she was diagnosed with type 2 diabetes. But losing her job due to her chronic condition means she is experiencing unemployment and can’t pay for her housing. Her lack of income also impacts her ability to make healthier food choices and she feels overwhelmed with the new demands of managing her medical treatment plan and her economic situation.

Sarah has found it very hard to face these changes and feels depressed and humiliated that she now has to seek help from social services. She is bordering on developing clinical depression and finds herself increasingly relying on her medical providers and social services workers for support.

These workers on the front line are Sarah’s lifeline to ensure she reaches her personal goals of stability and security in all aspects of her life. To achieve these outcomes, coordination between the health and social sectors is essential. Many people with chronic health issues (in this case diabetes) experience an ongoing loop of health problems and social impacts, as shown by statistics that:

• The unemployment rate for females with diabetes is almost 2.5 times higher than that of the control group¹
• Poor housing conditions are associated with an increased risk of developing diabetes²
• Persons with diabetes have demonstrated longer periods of unemployment and have lower incomes³
• Diabetes has been associated with increased occurrences of both depression and unemployment⁴
• Housing insecurity had a negative influence on diabetes processes of care and self-care behaviors, and this relationship was further impacted by employment status and race/ethnicity⁵

The true scale

We know that the experiences seen in Sarah’s situation are not rare. Sixty percent of adults (6 in 10) in the U.S. have at least one chronic disease, and 4 in 10 have two or more chronic illnesses.⁶ Chronic diseases are on the rise and will require attention from social services and health agencies for the foreseeable future. As we've seen, chronic medical conditions can drive increasing social needs and trigger behavioral and mental health conditions, creating additional challenges for individuals, families, and communities.

As the social protection needs of populations around the world become more complex, traditional service delivery models are struggling to meet new demands. Both the health and social program systems are under significant pressure.

A new approach

This is where a coordinated health and social outcomes (CHSO) approach will make an impact, increasing the likelihood of significantly improving public health and helping workers to tackle deep-rooted social challenges.

The transformation towards a fully person-centered service model (including families), with relevant services delivered by the appropriate agencies, challenges traditional thinking.

Peer insights

At the 2024 APHSA National Human Services Summit, there was a special focus on individuals and their families with lived-experience, and leveraging community resources, technology, and human-centered design for better outcomes.

Our Cúram team engaged with a group of agency and industry peers to discuss experiences that agencies are encountering as they launch initiatives for coordinated person-centered service delivery. The group reviewed how agencies can evaluate their maturity level and work from where they are to address challenges, using a framework of six key elements for coordinated health and social outcomes.

Starting with segmentation

It became clear during the discussion on coordinated health and social outcomes that many cities, counties, and states are faced with similar challenges around funding these efforts. Procurement processes don’t always work efficiently to provide effective speed-to-value, and there can often be complicated processes behind pulling together a business case across the social and health enterprise.

When facing these challenges, segmentation of the population can be a good place to start. Defining and starting with a small cohort and understanding their needs in detail is vital to investing resources where they can offer the most positive health and social impact. Starting with a small segment will clearly position the potential impact on outcomes, and can help to get agreement and movement for funding. For example, agencies can use analytics to identify and target a cohort of a certain age group with a specific chronic condition or multiple conditions. Or they can target participants in a specific program that are high-cost, high-need utilizers of services.

Continued coordination

It was also discussed that different organizations within the health and social programs ecosystem historically operate independently. Referral systems often take the form of a handover rather than a continuous service provision and differing payment models can be complex. Navigating this level of complexity can be difficult for the person that needs to access services in such a fragmented landscape.

Embracing both functional coordination and technological transformation across multiple services can help in the move towards person-centered service delivery. A success story was shared by a county agency that co-location of public health and social services has been key to seeing positive impacts. By bringing in community partners and health workers that share common functions with the social side, agencies can work together in a coordinated way as part of a tailored, holistic plan, focused on achieving positive outcomes for individuals and families.

Integration and interoperability

Technological coordination should also be considered as a key factor to support better collaboration across workflows, pathways and processes. This helps to provide the necessary information and insights to drive effective service delivery and usage.

County representatives in the session raised questions about navigating restrictions and complying with confidentiality issues such as HIPAA when coordinating across the health and social sectors. Consent and coordination of permissions are another critical element, and agencies must ensure that data is only shared across services with explicit consent of patients/clients, and in compliance with program regulations. Anonymized data is an important source for agencies to analyze the needs of its populations and to evaluate the success of its coordinated interventions. Agencies that have achieved secure data integration create the foundation for integrated and interoperable health and social program service provision. This is a complex step into broader technology concepts, which often involves experts in cybersecurity and program legislation be part of the team.

Operational transformation

One of the most significant hurdles related to coordination of health and social that was discussed is how to align key players from the various agencies with the mission. Strong communication lies at the heart of effective coordination for health and social outcomes, yet many organizations struggle to keep information flowing smoothly. In some cases, barriers to communication can come from high workload volumes and technical challenges around system interoperability. But, it can also be the result of service providers unintentionally deprioritizing external communications with other health and social programs organizations.

Executive sponsorship and ongoing commitment were identified as important elements in aligning key players and teams towards the shared goal. This is critical no matter what stage of coordination maturity the agency finds itself in. Starting from the earliest segmentation and targeting activities to identify expected outcomes for specific cohorts, communications and sponsorship of initiatives are critical to drive alignment on the necessary changes.

Technology Innovation

The most exciting and potentially transformative innovations in health and social programs are centered around outcomes, and in many cases digital technology is the foundation. Building upon the earlier identification analytics, at a later stage, advanced analytics could be used to support this coordination at scale. Health and social data can be used to segment broader populations and profile individuals to support further improved outcomes. Eventually those analytics can also be used to target individuals and families who are trending towards crisis and potentially predict those who might best benefit from earlier interventions.

One county shared during the discussion that they are already using tools to assess social determinants of health, and are now coordinating across the whole system to identify root causes creating the need for the services. As well as helping to safely and efficiently transition people from crisis to stability, advanced analytics may also be able to predict the needs of a cohort and prevent individuals from reaching crisis point.

Individual, family and community activation

Organizations are never addressing the needs of just an individual. A cohort must also take into account their family or caregivers. If a mother is impacted by a chronic condition, chances are that her family is sharing in the socio-economic impacts. Careful consideration around cohorts was discussed as necessary for effective segmentation to coordinate health and social service delivery.

This is especially important when it comes to driving successful outcomes. Encouraging people to improve their own self-care is key for long-term health and social conditions such as diabetes or unemployment, but a much more effective approach is to also involve the people around them; their families and communities. By including this wider network in a multidisciplinary approach to tailored plans, success is more likely.

Conclusion

In the U.S. today there is an ongoing trend to put the person at the center of care, and the 2024 APHSA National Human Services Summit provided an engaging experience for government and agency peers to discuss the evolution of coordinated health and social outcomes. Agencies are at varying stages of growing the coordination across health and social programs, with many diverse local initiatives underway to better integrate health and social services. The need to actively address putting the person at the center of the whole ecosystem is rapidly growing. With health conditions and social needs so closely linked, the impact on individuals and their families is growing as our society becomes more interconnected and interdependent.

Read the whitepaper to learn more about the framework for building effective coordination to support the best outcome for the individual