Case study 1
The Esther model
Health and care integration in Jönköping, Sweden – a collaborative approach to systems design
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 was seen by a district nurse and told to visit her general practitioner, who said that she needed to go to hospital and called an ambulance. After being admitted to emergency care she retold her story to a variety of clinicians at the hospital during a five-and-a-half- hour wait. Esther 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. 
In the late 1990s, with Esther’s experience in mind, the then head of the medical department of Höglandet Hospital in Nässjö, initiated an extensive series of interviews and workshops to identify redundancies and gaps in the medical and community care systems and develop an action plan for improvement.
‘Esther’ came to represent elderly persons who have complex care needs that involve a variety of providers.
The 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?
The now widely adopted Esther model uses continuous quality improvement, cross-organisational communication, problem-solving, and staff training to provide the best care for elderly patients with complex care needs. 
Further details of the application of a systems approach to this case study can be found in Annex 1: Applications of the approach.
The success of the Esther model may be attributed to:
using the ‘Esther’ persona to exemplify the need for coordinated care
involving multiple stakeholders to develop an improvement action plan
delivering multi-provider care experienced as if it were from the same provider
significant improvements in care leading to better outcomes for patients
 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