Publications

2025

“The Opportunities and Challenges of Integrating Health and Social Care in a Post-Stroke Patient Journey: Perceptions of Estonian Professionals”

You can read the full article here: ScienceDirect

Authors: Kadi Lubi (Senior Researcher, TalTech e-Health Centre), Maarja-Liis Elland (Junior Researcher, Institute of Health Technologies), Prof. Peeter Ross, Dr Katrin Gross-Paju (Head of the Neurology and Psychiatry Clinic, West Tallinn Central Hospital), and Helin Pevkur (Project Manager, West Tallinn Central Hospital).

Project Overview
West Tallinn Central Hospital conducted a project to analyse the potential for integrating health and social care, alongside the associated challenges, within the post-stroke patient journey.

In 2019, the Estonian Health Insurance Fund launched a pilot project to evaluate an integrated approach to post-stroke care. A key feature of this project was the immediate inclusion of local government social workers in the stroke team during the acute phase, with the first meeting taking place before the patient left the stroke centre. Working alongside district social workers, the project mapped opportunities for collaboration during the early stages of recovery. The qualitative analysis was based on in-depth interviews with eleven healthcare and social care professionals.

Key Findings
The results showed that early involvement of district social workers as part of a multidisciplinary team enables comprehensive, patient-centred care. Several bottlenecks were also identified, including limited resources (staff, time, and expertise) and lack of interoperability between information systems, which hindered the implementation of new processes.

The study concludes that a successful integrated service model requires coordinated health and social policy that actively supports cooperation between all parties. By involving city government social workers as immediate members of the stroke team, this pilot project effectively bridged the gap between medical care and social work.

The results were recently published in the international journal Health Policy (Vol. 159). The project was funded by the Estonian Health Insurance Fund.