Prioritising outcomes: a framework for coordinating complex cases across health and social protection services
How can health and social protection organisations collaborate to improve people’s lives and boost operational efficiency?
Health and social protection organisations around the world are facing unprecedented demand for their services — especially as populations age and economic volatility pushes more people into homelessness, poverty, loneliness and other associated social challenges.
For many people, particularly those with complex and chronic conditions, overcoming these issues can require intervention from both healthcare providers and social protection services. However, growing demand often means that these organisations aren’t always able to collaborate as often as they would like to. In turn, this can lead to the same individual receiving treatment and services from healthcare providers and social protection agencies from entirely different perspectives – and neither organisation having a clear, holistic view of the person’s needs.
“Taking a person-centred and coordinated approach to health and wellbeing is the stated goal of many systems across the world. There is still a gap between this vision and current practice. To bridge this gap we need to bring all of our collective creativity to bear, including a focus on digitally enabled care coordination.”
– Dr Niamh Lennox-Chhugani Chief Executive International Foundation for Integrated Care
Traditional service delivery models can make it harder for organisations and individuals to overcome health and social challenges. For instance, a recent study found that patients with poor social support have a readmission risk of 20%.1 While this is just one statistic, it points to a broader trend of how not treating people with an awareness of the interconnected nature between health and social issues can impact outcomes — adding yet more pressure to already stretched services.
What are Coordinated Health and Social Outcomes?
Cúram by Merative is committed to empowering providers of health and social protection services to guide people to the best possible outcomes. That’s why we developed the Coordinated Health and Social Outcomes (CHSO) model.
The CHSO approach is a brand-new service delivery model that aims to put people at the centre of their care journey. Through this model, healthcare providers and social protection organisations can work collaboratively to design holistic service plans that are tailored to a person’s health conditions and address their social challenges at the same time.
Redesigning service delivery with the CHSO approach doesn’t require agencies from the health and social sectors to carry out complex, time-consuming mergers. Rather, this approach aims to ensure that services and support from all stakeholders in a person’s service delivery chain (hospitals, social protection agencies, charities, community groups, family members and, of course, the person themselves) can combine their efforts and expertise seamlessly to support the needs of patients and service users.
Why is CHSO important for service providers?
Healthcare and social protection organisations often receive funding based on how well they meet key performance indicators, which are typically set by funding bodies or government. In many cases, healthcare providers track length of stay, treatment adherence, and readmission rates to measure and improve service quality and optimise resource allocation.
For a person with a chronic condition who requires regular hospital treatment and who might also rely on disability benefits to manage their condition, it is crucial that both the health and social elements of their care are aligned. If social protection service delivery or social support is too complex, delayed or inadequate, it could aggravate the individual’s health outcomes. Similarly, if a person’s health condition deteriorates because they don’t properly understand their treatment, or receive fragmented healthcare provision or incorrect treatment, they could lose their independence and need more help as a result.
If one agency struggles to deliver the correct support in a timely way, it could increase the pressure on the other stakeholders working with the same individual. In this scenario, valuable resources are wasted that could otherwise be better applied to help more patients and tackle emerging challenges.
Outlining the framework of the CHSO model
While times are challenging for many health and social protection services, the future is still bright for these organisations. New technologies such as analytics, wearable technology, cutting-edge medical devices and connectivity solutions promise to revolutionise medicine and social protection service delivery.
Combined with the CHSO approach, these new innovations can help governments, hospitals, and other care providers to overcome challenges. To redesign their services around CHSO effectively, health and social protection organisations should focus their efforts on six key areas:
- Segmentation
Understanding the needs of individuals and populations in detail is vital to investing resources where they can offer the most positive health and social impact. However, people’s needs vary tremendously based on a range of factors such as sex, age, weight, location, income level and education.
Using advanced analytics, health and social researchers can identify patterns of need in populations and then leverage this data to offer truly personalised, holistic care and social services for individuals at massive scale.
“Gathering and analysing information on a person’s health outlook and social situation will help providers address issues holistically. It’s clear from recent advancements that technologies such as big data analysis and artificial intelligence will play a huge part in helping organisations to achieve this.”
– Dr Mazin Gadir, Digital Health Advisor, UAE
- Coordination
Coordination is at the heart of the CHSO model and involves all stakeholders in a person’s care working together to improve outcomes. If every provider agrees to work towards shared goals, whether that’s improving an elderly person’s independence or helping an unemployed person with a chronic health condition get back to work, setting a clear target will help to ensure all actions and interventions are driving towards improved outcomes.
- Integration and interoperability
Taking a coordinated approach encourages organisations to find new ways of integrating services and information, leading to greater interoperability between stakeholders. That said, sharing data is not a panacea. Defining coordinated outcomes first will help organisations to understand the optimal level of collaboration and integration required to create better health and social outcomes.
- Self-activation management
Individuals, family, friends and wider community members play a huge role in helping people improve and manage their health issues and social challenges. If health and social protection organisations can tap into these resources and provide education around self-activation, then these organisations stand a better chance of reducing readmission rates and serving more people.
“Self-activation involving family members, communities and the person themselves is one of the most effective ways to help people stay out of hospital and manage their health and social conditions effectively over the long term.”
– Dr. Héctor Upegui, Coordinated Health and Social Outcomes Worldwide Market Development Executive, Merative
- Technological innovation
Technology has tremendous potential to help us overcome some of the most pressing health and social issues today. However, technology itself is a means to an end, not a miracle cure. Therefore, aligning the adoption of new technologies with coordinated outcomes is vital to ensuring that technology empowers organisations to define and deliver coordinated outcomes, rather than distract from this mission.
- Operational transformation
At its core, the CHSO approach aims to help health and social protection organisations move from a traditional process-based delivery model to a more person-centric approach. If organisations can make the transition effectively, they could dramatically reduce the workload for providers, improve the patient and service user experience, and unlock new efficiencies.
Learn more
Let’s use the CHSO model to revolutionise the way we design, deliver and manage healthcare and social protection services - and, ultimately, drive better outcomes for individual patients, organisations and society as a whole.
If you’d like to find out more about Coordinated Health and Social Outcomes, you can read the full white paper here.
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References
- Navathe, A.S., Zhong, F., Lei, V.J.,Chang, F.Y., Sordo, M., Topaz, M. Navathe, S. B., Rocha, R. A., Zhou, L. (2018). Hospital Readmission and Social Risk Factors Identifies from Physician Notes. Health Services Research 53(2), 1110-1136.
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