Coordinated health and social strategies create seamless care pathways

Merative, specialists in healthcare data, analytics and technology, recently published a whitepaper that highlights the foundation of establishing coordinated health and social protection services and its impact on the patients, healthcare providers, as well as costs and resources. It further addresses the need for regulations and security around data integration for interoperability.

Excerpts from an interview with Dr. Héctor Upegui, Worldwide Market Development Executive, at Merative:

Tell us about your recently published whitepaper on Coordinated Health and Social Outcomes.

The Coordinated Health and Social Outcomes (CHSO) whitepaper is centred on coordinating services for better outcomes. This involves outcomes for organisations providing health services or social protection services, and of course, outcomes for the person their family, and the community.

Coordinated health and social outcomes – or what we call “CHSO” — is a person-centric service delivery model where health and social services are provided in a coordinated way to improve outcomes.

It does not require merging agencies or governmental bodies, but it is an approach that involves all stakeholders, including the person receiving the service. It is a model to enhance the flow of service so that the person does not navigate alone through all this complexity, instead the system adequately rotates around the person. It goes beyond just aligning health and social care services, or just organising them as checklists for execution. It is also about understanding the needs of the person, the service delivery process, the rationale behind it, and the best route to reach outcomes.


Dr. Héctor Upegui

Why is it important to healthcare organisations and whom will it benefit?

Healthcare organisations have crucial goals around treatment adherence, length of stay and readmission targets.

For much of the population, the social needs of an individual will impact their personal health outcomes, which in turn will impact the goals of the healthcare provider whose services they require.

Some health conditions can be worsened by factors such as housing and food insecurity. An older person with diabetes from a low socioeconomic background who lives alone may be at higher risk of hospital readmission, for example, because they have nobody to help with their shopping, which could reduce their access to nutritious food. Coordination of social support from community volunteers to organise food drop-offs could help reduce the risk of hospitalisation, impacting health outcomes, and therefore positively contributing to the goals of the organisation.

The coordinated health and social outcomes (CHSO) model recognises that health and social issues are inextricably linked and that addressing each in isolation is unlikely to meet with success. A social worker based in a healthcare setting will benefit from access to data about the whole person, not just the health data or the social data in isolation. The more they can understand about the person, the better enabled they are to provide a tailored plan of services.

The CHSO ambition is to build coordinated plans that treat the whole person, for example, pulling relevant social data, or data from secondary sources, into the socio-medical electronic record alongside the health data, to better serve individuals based on their needs. Advanced analytics could be used to support this coordination at scale, using health and social data to segment populations and profile individuals to support improved outcomes.

Of course, when we talk about sharing data, it may only be shared across services and with users’ explicit consent, and in compliance with data protection regulations. Data integration must be secure, complying with regulatory provisions such as anonymisation and consent, creating the foundation for integrated and interoperable health and social protection service provision.

What does this mean for individuals and the community?

Much of the population will either have experienced themselves or will know someone who is dealing with health and social issues at the same time. For example, chronic diseases are becoming more prevalent. Individuals with chronic issues are dealing with different medical appointments and diagnostics, and if they are unemployed, on income support or social protection benefits or disabilities insurance, they are navigating the complex world of both the health services and the social protection services at the same time. Juggling home life whilst managing their interactions with multiple points of contact across these services can be confusing and stressful. It can even mean that individuals miss out on available support.

If organisations across the ecosystem were better coordinated around the person, it could greatly improve experiences for the individual and their family and could help to reduce waste and duplication in terms of health and social resources accessed. But most importantly, it has the potential to improve outcomes for the person themselves, which then of course, impacts organisational KPIs around cost, treatment adherence, and the length of stay, for example.

In addition to providing seamless care pathways, health and other social protection organisations that establish effective CHSO-based services successfully empower individuals, families, and communities to develop strong self-care practices.

Encouraging people to improve self-care is especially important for long-term health and social conditions such as diabetes, disability, and unemployment, to mention a few, and it also plays a crucial role in reducing pressure on health and other social protection organisations.

This self-activation of individuals can help communities to become more resilient.

Tell us about Merative’s role in relation to CHSO.

The Ministry of Health Riyadh Cluster in Saudi Arabia is collaborating with Merative and Obeikan Health to introduce Merative Social Program Management alongside Obeikan Health’s case management system. They are known together as the saned platform, built to facilitate coordination between health and social outcomes activities, as well as support social workers in a hospital setting, helping to improve clinical KPIs such as hospital readmissions, the average length of stay and adherence to treatment plans.

Looking ahead, how do you see this evolving?

Many of the most pressing challenges in the world today, from ageing populations to the increasing prevalence of chronic disease and rising inequality, place tremendous pressure on the resources and capacity of health and other social protection systems.

Humans are complex beings, with complex needs, and the complexity is growing due to these challenges. As the complexity of service needs grows, the need for coordinated health and care outcomes becomes more and more important, to reduce stress on systems, organisations, the people who work there, the people receiving the services, their families, and the wider community.

Discover the six key elements behind building effective coordinated health and social outcomes to support the best outcome for the individual. Download the free whitepaper by Merative now.

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