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.6 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.









Figure X:

Improvement tools, such as the IHI model for improvement, the NHS house of quality and driver diagrams can complement the activities of a systems approach that in turn can add new tools and ways of thinking to existing improvement approaches.

Share this page


[1] xxxxxxxxxxxxx

[2] xxxxxxxxxxxxx

[3] xxxxxxxxxxxxx

Explore more...

Find out what's useful to you


Executive summary


Section 1

Healthcare as a ‘system of systems’

Section 2

Approaches to improvement

Section 3

Defining a systems approach

Section 4

A framework for thinking

Section 5

A framework for action

Annex 1

Applications of the approach

Annex 2

Case studies

Annex 3

Elements of a systems approach

Annex 4

Compilation of approaches


About the project