Project PAIK

What is this project?

The PAIK project is an area-specific support service for providing continuous healthcare and top social services in Viljandi County.

PAIK is a pilot project initiated by Viljandi Hospital and the Ministry of Social Affairs and funded by the Estonian Health Insurance Fund. This project combines health and social care parties for the benefit of people: family physician, specialist doctors, local government social worker and pharmacist, the community and family.

Led by project manager Mart Kulli, Viljandi Hospital is heading the project.

Project objectives

– Improving cooperation between healthcare areas and the social system.  

– Providing support for patients coping with chronic disease.

– Valuing a patient-focused approach in the treatment process.

– Reducing overlap in health and social care.

Target group

Residents in the Viljandi area who have been diagnosed with a chronic condition and require social support.

For the purposes of the PAIK service, service providers are the healthcare and social work specialists and volunteers in the patient's network. Specialists are involved in the team based on the patient's need for help and their consent.

The PAIK health manager is a social worker or a specialist trained as a nurse who will perform and coordinate the preparation of the patient's health plan and the monitoring thereof. The health manager takes a team-based approach to work with people with chronic disease, their support network, providers of health and social services and the community's resources in order to help patients manage in their own homes.

Of the four PAIK health managers in Viljandi Hospital's PAIK team, two are qualified nurses and two are qualified social workers.

Family physicians, family nurses and local government social workers are important members of the clients' networks and take part in network meetings as agreed with the health manager and based on circumstantial need (by phone, videocall or participating in network meetings in person).

Provision of the PAIK service

• NOTICE

PAIK patients in the hospital, during doctors' appointments, in the local government or at home.

• UNDERSTAND

• PLAN

any necessary activities, the team and a time schedule.

• HELP

professionally and in any vital way, keeping interactions simple and kind.

Content of service

Patients' suitability for the project is assessed based on agreed criteria. A family physician or a specialist may refer the patient to receive the service.

The PAIK health manager will introduce the content of the service to the patient and determine the need for the service with the patient. The patient signs a consent form.

The PAIK health manager will assess the health of the patient and their ability to manage together with the patient by employing various assessment instruments, medical documentation and specialist assessments. This is then used to outline important issues and the patient's goals.

A support network of specialists is assembled based on the patient's needs. The network is a team that supports the treatment and management of the patient and is comprised of a family physician, a family nurse, the patient's loved ones, a social worker, (a) local government representative(s), a home nurse, a physiotherapist and other specialists that help the patient manage better (e.g. nutritional specialist, pharmacist, neighbour), who are added to the network based on the needs and consent of the patient. Patients are the most important members of the network.

Together, the network agrees on an action plan to look after and provide the best possible support for the health of the patient, i.e. the patient's health plan is drawn up. The patient's health plan contains the patient's objectives and potential actions for reaching those objectives. The health plan is a common agreement between the members of the network to support the patient's health, their ability to cope and their need for help as well as to meet the patient's personal objectives.

The health manager monitors and supports the execution of the action plan and regularly contacts the patients and network members.

The central idea behind the provision of integrated services is ensuring communication between service providers. IT solution Teleskoop was created to this end. Teleskoop is an extra module to the hospital's information system that intermediates essential information about people between the members of the integrated services team. Teleskoop establishes a common information field between parties.

Establishing contact -> Considering needs and objectives -> Joint planning -> Coordinating services -> Communication