The World Bank: risk-stratified care management and coordination at the frontier of health policies

On 2 December, EHIF welcomed the World Bank’s representative Daniel Rogger who is the lead of the enhanced care management research team. The purpose of the visit was to introduce the results of the EHIF’s second pilot and to make summaries on the ongoing cooperation.

More and more people suffer from chronic diseases (e.g., diabetes, cardiovascular diseases) both worldwide and in Estonia, and these people need to have their health status regularly monitored by a healthcare professional.  In Estonia, risk-stratified care management approach was first introduced in primary care to provide better help to high-risk patients who usually suffer from several chronic diseases, other accompanying conditions and are at high risk of health status deterioration and increased healthcare utilization.

"The model aims at creating a working tool for family physicians and family nurses, which can be used to act proactively in order to avoid the deterioration of the condition of chronically ill patients and to better manage their care process in cooperation with specialized medical care and the social system," said Jekaterina Šteinmiller, lead of the high-risk patient care management project at EHIF.

"By supporting clinics across Estonia to define a new 'partnership' with patients to improve their health, the program is at the frontier of health policies targeting long-term sick," explained Daniel Rogers, the lead of the World Bank’s Development Research Group.

The World Bank, EHIF and the Estonian Family Physicians Association started the pilot of risk-stratified care management approach already in 2017. Since the results of the first pilot confirmed that in the long term it is worthwhile to implement risk-stratified care management nationally, the model was expanded during the period of 2020-2022 and even more family physicians and family nurses were included in the team of the second pilot. Today, the second pilot has also been successfully completed, and it is time to draw conclusions.

The World Bank, supported by researchers, have collaborated with EHIF over the past three years to design and evaluate the rollout of an innovative new program. The World Bank’s support included inputs into the design of the high-risk patients’ pilot program, including contributions from international best practice, measurement and evaluation. “The World Bank and EHIF teams worked intimately across the period to bridge frontier methods of analytics to ensure they had a detailed understanding of how clinics were changing their practices due to the program and whether there were resulting changes in patient health outcomes,” Rogger explained.

The pilot included 96 randomly selected practice lists with more than 2000 patients. More than 70% of family physicians were satisfied with risk-stratified care management and found it a valuable tool to improve the monitoring of chronically ill patients. Most physicians wanted to continue with risk-stratified care management even after the pilot had ended.

The results show that, thanks to the pilot, the care management for chronically ill patients has become more patient-centred and the number of visits to family physicians, as well as the number of consultations with family nurses have increased. For example, family physicians’ teams have started to regularly discuss the clinical histories of high-risk patients, they review treatment plans together with patients and the patients are assisted in setting personal treatment goals and evaluating health outcomes. As a result, the family physicians’ teams also noticed changes in the health behaviour of high-risk patients. Furthermore, the results show reductions in aggregate hospitalization of high-risk patients.

At the same time, more than half of the physicians admitted that this approach to the care of chronically ill patients requires more time. One of the biggest challenges is insufficient cooperation with social assistance authorities to support chronically ill patients, who also face socio-economic problems.

The pilot also confirmed that care coordinators are an essential link in modern primary care. With their help, the family physician’s team received necessary preparation and support throughout the program. "As a care coordinator, I was able to support and oversee the entire care team. The pilot was launched during the COVID-19 pandemic, which was a challenging period for family physicians and nurses, but the availability of a personal coordinator's support gave them confidence to join the project," Alieene Juuse, a care coordinator, said.

According to Ilja Tšibisov, another care coordinator, their goal was to convince family physicians and nurses that risk-stratified care management helped coordinate the care process of chronically ill patients more thoroughly. "We approached each family physician and nurse individually, supporting them in many ways, which led to 96 family physicians and primary care centres to join the pilot," Tšibisov added.

"The results of the pilots showed that risk-stratified care management has a clear potential to improve the integration of our healthcare services, the treatment of chronically ill patients, and in the long term, also the health outcomes of patients as well as the quality of care. For this reason, we are considering adding risk-stratified care management as a service to the list of healthcare services in the near future," Šteinmiller stated.

"It has been an absolute pleasure working with the team at EHIF," said Daniel Rogger, lead of the World Bank's research team, "and we have learnt as much and more from working with our Estonian counterparts as they have learnt from us. This program is another example of Estonia's commitment to innovative public policy, and it will provide benefits for the Estonian people, and lessons for governments around the world,“ Rogger added, praising Estonia as an exemplary model at the end of his visit.