Annex 1 : Applications of the approach
The Esther Model, health and care integration in Jönköping, Sweden
The answers that follow represent those that may have been formulated by the end of the programme, accepting that there was some iteration between the people, systems and design elements of the work. They are nonetheless representative of the systems approach originally applied to the challenge of improving the care for elderly persons.
Why are we doing this?
Esther lived alone and one morning developed breathing difficulties. After contacting her daughter, who did not know what to do, Esther sought medical advice. She saw a total of 36 different people and had to retell her story at every point, while having problems breathing. A doctor finally admitted her to a hospital ward. This case inspired the head of the medical department of Höglandet Hospital in Nässjö to initiate an extensive series of interviews and workshops to identify redundancies and gaps in the medical and community care systems.
What is the problem?
Elderly patients with complex care needs may receive services from multiple specialists, as well as primary care physicians. In addition, they may visit emergency departments, have frequent hospitalisations and post-hospital rehabilitations, and receive long-term care services at their home or in nursing facilities. The central idea was that care should be guided by the following questions: What does Esther need? What does she want? What is important to her when she is not well? What does she need when she leaves the hospital? Which providers must cooperate to meet Esther’s needs?
Who will use the system?
Elderly persons who have complex care needs that involve a variety of providers, along with carers and a number of health and care professionals.
Where is the system?
The Höglandet (Highland) region (population: 110,000) in Jönköping County, in the south of Sweden, where the county has 34 primary care centres and three acute hospitals, with a total health workforce of 9,500, serving a local population of 350,000 across 11 municipalities.
What affects the system?
Care coordination in Sweden is complicated by a legal structure that gives the country’s 21 counties responsibility for funding and providing hospital and physician services while the 290 municipalities are responsible for funding and providing community care. Home health care (nursing services for sick patients) and home care (assistance with activities of daily living) are also provided by different professionals.
Who should be involved?
Patients and carers, and people involved in the supply, management and control of care for elderly people, such as physicians, nurses, social workers, other providers representing the Höglandet Hospital and physician practices in each of the six municipalities.
Who are the stakeholders?
Stakeholders are those that have an interest in the successful performance of the system and can be described by their role title, need(s) and purpose:
As a patient:
I need care in or close to my home so that I can stay at home. I need to experience care from multiple providers as if it were from the same provider so that they all know my medical history. I need to have care uniformly available throughout the region so that I feel free to travel, and I need to know who to turn to when problems arise so that I feel safe.
As a carer:
I need to understand Esther’s needs so that I can help care for her, and I need to know who to call if Esther needs help so that I can be sure of talking to someone who knows her.
As a neighbour:
I need to have a contact number for emergencies so that I can quickly summon medical assistance.
As a primary care physician:
I need to provide the best care possible for Esther in the community so that her medical needs are met locally as far as is possible. I need access to Esther’s full medical history so that I know what treatment may have been provided by the hospital and what level of social care is being provided.
As a specialist:
I need to supply oral methotrexate in a form so that pharmacies can adjust the quality dispensed to meet individual patient needs, and I need to sell sufficient quantity of oral methotrexate so that the product line is commercially viable.
As a pharmacist:
I need access to Esther’s medical history so that I can check that her medications are safe to be taken together.
As a hospital physician:
I need access to Esther’s medical history so that I can prescribe the most appropriate treatment, and I need to be sure that appropriate care is available so that I can safely discharge Esther from hospital.
As a specialist:
I need access to Esther’s medical history so that I can provide appropriate specialist treatment as required.
As a nurse:
I need access to Esther’s medical history so that I can care for her, and I need to know Esther so that I can do what is best for her.
As a home healthcare worker:
I need access to Esther’s medical history so that I understand her care needs, and I need to know Esther so that I can do what is best for her.
As a home care worker:
I need to have a contact number for emergencies so that I can be sure of talking to someone who knows her, and I need to know Esther so that I can do what is best for her.
As a hospital manager:
I need to understand Esther’s care needs so that I can ensure she receives the care she needs and coordinate her discharge from hospital. I need to ensure she remains in hospital only as long as is medically required so that I can manage my budget wisely.
As a community care manager:
I need to understand Esther’s care needs so that I can coordinate her care, and I need to be consulted if she is to be discharged from hospital so that her immediate care needs can be met.
As a service provider:
I need to ensure that I meet Esther’s care needs so that I can do what is best for her, and I need to know how well I am meeting her needs so that I can continuously improve the care I am able to provide.
As a funder:
I need to be confident that the money I provide for the care of elderly persons is spent wisely so that the benefit of good care is provided for all.
As an administrator:
I need to ensure good communication between care providers so that they understand Esther’s medical and care needs and provide coordinated care for her.
What does good look like?
Success will be measured by Esther getting care in or close to home, experiencing care from multiple providers as if it were from the same provider, having care uniformly available throughout the region and knowing who to turn to when problems arise.
What are the elements?
The elements of the system can be considered to be Esther and her family and neighbours, the people who provide all aspects of medical and home care to her, the geographical and transport systems around her home and points of care, the organisations that facilitate her care, and the bodies that fund her care.
What are the needs?
The analysis of interviews with over 60 patients and providers throughout the system identified six key needs for action: 
- The development of a flexible organisation with patient value in focus.
- The design of more efficient and improved prescription and
- medication routines.
- The creation of approaches to documentation and communication of information that can be adapted to the next link of the care chain.
- The provision of efficient IT-support through the whole care chain.
- The provision of a diagnosis system for community care.
- The development of a virtual competence centre for better transfer and improvement of competence through the care chain.
How can the needs be met?
Many of the problems experienced by Esther involved more than one organisation. It was important to bring together people from different levels in these organisations to develop and deliver solutions to support the needs identified. These included:
- A steering committee of the community care chiefs from municipalities, hospitals and primary care centres to address challenges across organisations.
- Four ‘Esther cafés’ in municipalities each year, which were cross-organisational, multiprofessional meetings for sharing and learning from the experiences of specific patients who were hospitalised in the past year and have continued on to home care or other services.
- Interorganisational training workshops on palliative care, nutrition and fall prevention, among other topics.
- An annual ‘strategy day’ for nurses and other staff, physicians, managers, as well as ‘Esthers’ themselves to come together to team build and generate priorities and ideas for addressing problems in care.
In 2006 coaches were introduced to the model to promote the Esther Network vision and values and to support ongoing improvement. The aim was to develop internal coaches to facilitate improvement across organisational boundaries, providing: customer focus, modelled by involvement of senior citizens in the training programme; a shared set of values; networking skills with a solution-focused approach; and systems thinking.
How well are the needs met?
The Esther model calls for continuous and coordinated improvement with a focus on providing what is best for Esther. The evidence points to a cultural shift in the way leaders and workers in the Jönköping County health and care systems now provide for Esther, facilitated by the solutions introduced in response to her needs — “the focus is on her now.”  It is also evident that the changes have not only been sustained and further developed, but also have provided the inspiration for change in other health and care systems around the world.
What could go wrong?
Proactive risk assessment was not employed within this programme. However, the impact of the changes introduced were continuously monitored.
How does the system perform?
This innovation programme was not designed as a research project and involved many organisational and process changes that were introduced in different components of the model at different times. Therefore, it is important to be cautious in assessing the impact of the Esther model. Positive changes are noted, but it is difficult to attribute them to the model in the absence of comparative information. With this in mind, program leaders cite the following outcomes:
- Admissions to the medical department of Höglandet Hospital declined from 9,300 in 1998 to 6,500 in 2013.
- Hospital readmissions within 30 days for patients age 65 and older dropped from 17.4% in 2012 to 15.9% in 2014.
- Hospital lengths of stay decreased between 2009 and 2014 for surgery (from 3.6 to 3.0 days) and rehabilitation (from 19.2 to 9.2 days).
- Surveys conducted in Jönköping in 2008 and 2011 showed that Esthers felt safe and were appreciative of the personal contacts.
What should we do next?
“Taking a system approach to meeting the needs of the frail elderly is unusual, difficult, and necessary.” The Esther model depends on “the power of patients’ stories”, which were elicited and collected as part of the model to show how patients’ lives are affected by their health challenges and their experiences in getting care. The model creates mechanisms, including an annual retreat and development of action plans for each forthcoming year, to help members of different professions to continue to think together to solve problems and help to motivate the coaches. “The secret of Esther is the change in state of mind — stop thinking what is best for my organisation, but instead think what is best for Esther.” 
 Sweden’s Esther Model: Improving Care for Elderly Patients with Complex Needs, The Commonwealth Fund, New York, 2016. www.commonwealthfund.org/publications/case-studies/2016/sep/sweden-esther-case-study
 Is Sweden’s model of integrated care a beacon of light for the NHS? NHS Voices, NHS Confederation, 2015. www.nhsconfed.org/blog/2015/01/is-sweden-s-model-of-integrated-care-a-beacon-of-light-for-the-nhs
 Sweden’s Esther Model (see footnote 5)
 Improving Patient Flow: The Esther Project in Sweden, Institute for Healthcare Improvement, Boston. www.ihi.org/resources/Pages/ImprovementStories/ImprovingPatientFlowTheEstherProjectinSweden.aspx
 What Is Best for Esther? Building Improvement Coaching Capacity With and for Users in Health and Social Care— A Case Study. Vackerberg et al., Qual Manag Health Care, 25(1):53-60, 2016.
 Improving Patient Flow (see footnote 8)
 Sustained improvement? Findings from an independent case study of the Jönköping quality program. Øvretveit and Staines, Qual Manag Health Care, 16(1):68-83, 2007. www.ncbi.nlm.nih.gov/pubmed/17235253/
 Sweden’s Esther Model (see footnote 5)
 Is Sweden’s model of integrated care a beacon of light (see footnote 6)