Heading to

the future
Coordinated Health and Social Outcomes (CHSO)
Dr. Hector Upegui, Sean Renner

Imagine a single parent

with complex diabetes and
cardiovascular complications,
living alone in poor conditions
with food insecurity. Which
appointments come first? How
does food assistance, child care
and financial counseling align
with visits to the endocrinologist
and the cardiologist?
This is just one example of the complexity for one person with
multiple needs to manage, as well as all the stakeholders involved
in the service delivery. It’s an all-too familiar story. What is the best
way to achieve outcomes for people with complex health and social
situations? Coordinated Health and Social Outcomes (CHSO) can help
organizations answer this complexity.
3 trends shaping the need for a
new approach to CHSO

While the pandemic may be widening the gap for people at the
intersection of health and social services, the need for coordination is
nothing new. But there are three trends emerging that are shaping the
future and the way it can be delivered:

Increasing needs for services

People’s needs were changing the shift of traditional to non-

before COVID-19, and the traditional occupational risks.2
pandemic has augmented many The financial crisis increased
of these trends. For example, the needs for social security and
global population is aging – the social assistance services, again
share of the population aged exacerbated by COVID-19.
65 years or older has increased People are often affected by
from 6% in 1990 to 9% in 2019 multiple needs and must follow
– and this group tends to require complex service paths that are
more health and social care disconnected. Consider some
resources. There are more people recent examples of how health
with disabilities due to a global and social challenges have
increase in chronic diseases, intensified one another over the
armed conflicts and violence, and past few years:

1:4
The American Diabetes
Association surveyed
Americans with diabetes and
found that 1 in 4 report that
the pandemic has disrupted
their ability to get healthy
food, which is twice the rate of
food insecurity in the general
population.3

57%
The Danish Diabetes
Association surveyed a sample
of people with diabetes, and
57% reported that they often
or sometimes felt left out,4
which is double the rate given
in 2016.

75%
In a recent report from the
Office for National Statistics in
the UK, three-quarters (75%)
of disabled people said they
were either “very worried” or
“somewhat worried” compared
with 66% of non-disabled
people.5
People expect more

The relationships between physician-patient and social worker-citizen

are rapidly changing. Patients and citizens bear more responsibility
for managing their own care, and they increasingly expect consumer-
friendly options that they encounter in other areas of their lives. Users
are pushing for less or more depending on their own pre-conceptions
or definitions. People expect personalized, high-quality services,
anytime from anywhere, while keeping personal health and social data
private and secure.

Technology is more advanced

Processors are faster, cheaper and more accessible than in the

past. Moving to the cloud helps enable immediate access to
services providing scalability, security and flexibility to better serve
organizations, developers and end users. Computing power has
evolved to manage vast amounts of data, and analytics perform at
extraordinary levels to crunch both structured and unstructured data
in seconds.

With increased needs, changing expectations and better technology,

the timing is right for a new modern approach to service delivery.
Coordinated Health and Social
Outcomes (CHSO)
CHSO is a person-centric service navigate alone through all this
delivery model where health and complexity, but that the system
social services are provided in adequately rotates around the
a coordinated way to improve person. It goes beyond just
outcomes. aligning health and social care
services, or just organizing them
It does not require merging as check lists for execution. It is
agencies or governmental bodies, about understanding the needs
but it’s an approach that involves of the person, the service delivery
all stakeholders, including the process, the rationale behind it
person receiving the service. It’s and the best route in reaching
a model to enhance the flow of outcomes.
service, so that the person doesn’t

Operational
Technology
support Segmentation

Self care Integration

Coordination

To provide person-centric care, A concrete vision is essential

health and social services need to bringing together these six
to improve their coordination elements of care transformation.
of care. There are six common
elements to align to achieve
care transformation:6

– Segmentation
– Integration
– Coordination
– Self-care management
– Technology support
– Operational
The first step in achieving CHSO: Learn more:
Define a vision ibm.com/watsonhealth

© Copyright IBM Corporation 2021. IBM Corporation,

Watson Health, New Orchard Road, Armonk, NY 10504

Produced in the United States of America, April 2021.

IBM, the IBM logo, ibm.com, are trademarks of

International Business Machines Corp., registered in
many jurisdictions worldwide. Other product and service
names might be trademarks of IBM or other companies.
A current list of IBM trademarks is available on the web
at “Copyright and trademark information” at www.ibm.
com/legal/copytrade.shtml.

The performance data and client examples cited

are presented for illustrative purposes only. Actual
performance results may vary depending on specific
configurations and operating conditions. If applicable,
consult with your IBM legal contact to craft a
competitive claims disclaimer. If applicable, add the
other IBM products, services, or programs disclaimer.
THE INFORMATION IN THIS DOCUMENT IS PROVIDED
What should be the overall goal for example, segmentation helps “AS IS” WITHOUT ANY WARRANTY, EXPRESS OR
a person living alone, unemployed, identify the population, at the IMPLIED, INCLUDING WITHOUT ANY WARRANTIES
OF MERCHANTABILITY, FITNESS FOR A PARTICULAR
and struggling with depression intersection of health and social, PURPOSE AND ANY WARRANTY OR CONDITION OF
and diabetes? The current health set shared outcomes, visualize the NON-INFRINGEMENT. IBM products are warranted
according to the terms and conditions of the agreements
and social services climate teams that need to be involved, under which they are provided. If comarketed, add the
requires the individual to contact agree on what data needs to be disclaimer statement to this section.

multiple points of contacts, repeat shared, and prioritize and define

the story several times, and service delivery.
directly manage expectations from
one provider to the next. These challenges cross
individuals, families, communities
Healthcare and the social sector and organizations, demanding
currently operate in siloes, but multi-dimensional, multi-
there should be a holistic care disciplinary and multi-sectorial
plan when a person is at the actions. It’s become evident that
intersection of these disciplines, our health and social systems
meaning those facing health and need to find opportunities
social situations simultaneously. to work together. With the
Defining that plan is paramount to increasing needs for services,
being able to properly align the six people expecting more of their
elements of care transformation. providers and rapid technological
However, setting a vision and advancements, it’s clear that the
properly aligning it for outcomes future requires more coordination
are the key to success. For of care.

1. United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population
Ageing 2019: Highlights (ST/ESA/SER.A/430)
2. Upegui H, O’Riordan E, Duggan M. Disability Management: Trends and Emerging Strategies.; 2014.
3. https://www.diabetes.org/newsroom/press-releases/COVID-19-brings-crisis-of-access-for-millions-living-
with-diabetes
4. Joensen LE, Madsen KP, Holm L, et al. Diabetes and COVID-19: psychosocial consequences of the COVID-19
pandemic in people with diabetes in Denmark—what characterizes people with high levels of COVID-19-related
worries? Diabet Med. 2020;37(7):1146-1154. doi:10.1111/dme.14319
5. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/
coronaviruscovid19rounduppeopleandsocialimpacts/2020-07-03
6. Upegui H et al, “The six elements of care transformation”, manuscript. To be published