Estonian care management program pilot

In 2015, the Estonian Health Insurance Fund signed a cooperation agreement with the World Bank to continue analysis for the purposes of disease prevention, and improving access to health services; and the development of the health care system. One of the goals of stage II of the study is to develop a model that would help family physicians identify in their lists, the patients whom the implementation of the preventive, advisory and monitoring activities, would most benefit, a) patient's health and quality of life, b) at the same time supporting the optimal use of health insurance resources. Today, the World Bank in cooperation with the Health Insurance Fund, and with the family physicians participating in the project, have developed an evidence-based model of risk patients and started piloting the model on 15 February 2017. The piloting of the model is planned in the practice of the family physicians participating in the World Bank project. In total, the projects involve eleven family physicians from different regions of Estonia. The pilot project is scheduled to last six months, the final deadline being 31 August 2017. Developing the evidence-based model of risk patients is targeted especially for Estonian family physicians using international studies and international experience, linking it to the Estonian studies and experience. The aim of the model is to create a tool for primary health care workers (family physician and a family nurse) to identify better and manage the treatment process of chronically ill patients, integrating them with specialist medical care and social systems.

This is in order, through a monitoring system of chronically ill patients, to prevent as much as possible the exacerbation of the disease and thus to minimize hospitalization (including the importance of cooperation in primary and specialized medical care), thereby improving health outcomes, as well as to support mutual cooperation of social and health care systems.

In the first stage of the preparation of the pilot project (January - February 2017), a patient monitoring web environment was developed for family physicians. This means that important data for family physicians (consisting of the health indicators and the medical history of the risk patients, as well as of the reference to the patient's socio-economic background) is located in the online environment, where the family physician and the family nurse will have an overview of the health indicators of the so-called risk patients, and of the set treatment goals, based on planned activities, and can then monitor the implementation of the treatment plan.

The activities of the family physician and the family nurse include the following activities:

a) assessment of the risk patients’ needs and planning of treatment;

b) the coordination of health-related activities;

c) the coordination of the issues of social assistance (cooperation with a social worker).

In the course of the pilot project, family physicians may need to cooperate with hospitals in order to better monitor the course of the treatment of the patients on their list.

At the final stage, a project evaluation will be carried out in order to obtain feedback on the possible applicability of the project in all the family health organizations in Estonia.

What is Treatment Management?

Treatment Management is a means of improving the coordination of the treatment of the patients with complex and increased medical needs, both between the various levels of the health care, the social system, and between various providers of health care and social services. Treatment Management includes directional and preventive actions to a small portion of patients who are at high risk of health deterioration, or the risk of the increased use of health care services. Such actions may include, for example, patient monitoring after hospitalization, monitoring of referral to a medical specialist, and the results of the examinations; monitoring of the performance of the goals described in the family physicians’ quality system; ensuring the drug compatibility control and the usage; and monitoring of patients between scheduled appointments. Treatment Management is designed to address the needs of complicated patients in order to improve their health outcomes and reduce their need for more extensive health care services.  

Upon developing the evidence-based model of risk patients, targeted especially for Estonian family physicians, the Estonian Health Insurance Fund and the World Bank used international studies and international experience, linking it to the Estonian studies and experience.

Why is Treatment Management necessary?

All over the world, those who have a difficult socio-economic background make up only a small part of primary care patients, whereas the disease burden and health care costs of the people with lower socio-economic backgrounds account for a disproportionately large percentage. Many of these patients have multiple chronic diseases at one time, and they are confronted with major socio-economic problems, and/or simultaneously, they also have behavioral health comorbidities. They are likely to consume many different medications, visit several different medical specialists, and/or have significant functional restrictions.  Such characteristics may make coordination of the patient’s care difficult for primary health care providers, but failure to do so could lead to serious problems including unnecessary deterioration of health, duplication of examinations, mutual conflicts of the medication prescribed for treatment, and treatment errors. Treatment Management programs have a great potential for the improvement of  treatment coordination and patient’s treatment outcomes, and these programs are increasingly used by many different national health care systems.


The objectives of this pilot project are:

a.     To assess the applicability of the risk patients’ Treatment Management model developed under the pilot project;

b.    To understand the impact of the pilot project on the Treatment Management processes, and on the treatment results of patients enrolled in the program;

c.     Based on the experience gained, to develop risk patients’ Treatment Management models and solutions that will function in Estonia, and their application.

The ultimate goal of the Treatment Management program is to improve the health outcomes of patients with chronic diseases and complex needs and to reduce their need for health care services.


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