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  • Project PAIK

    Cooperation for the patient

    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.

    Service providers

    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.

    the patient's needs comprehensively – their ailments, social issues, day-to-day life, mood and attitudes.

    • 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

    Project timeline

    • Start

      19 October 2016 can be considered the starting point of the pilot project when Civitta Eesti, winner of the public procurement initiated by the Ministry of Social Affairs, with its co-tenderers Velvet DP and Leego, started to develop an integrated service, i.e. the PAIK model, with Viljandi Hospital by involving several parties in and outside Viljandi County.

    • Model for the establishment of integrated services

      The project 'Pre-analysis and planning of integration of regional health and social services' [Paikkondlike tervishoiu- ja sotsiaalteenuste integreerimise eelanalüüs ja kavandamine (PAIK)] initiated by the Ministry of Social Affairs finished in December 2017. The pilot project analysed the current situation and people's needs in Viljandi County and developed a model for creating integrated services based on people's needs. 
    • IT solution Teleskoop

      Based on the terms of reference of the PAIK project, IT solution Teleskoop was created on the basis of ESTER, the hospital's information system that has been available on users' desktops since the beginning of 2018. The purpose of this solution is to test whether the developed function is suitable for real-life situations.

    • Start of the pilot project

      Piloting started in June 2018 in the area of mental health. Somatics was added in autumn of that year.

    • Funding

      A funding agreement with the Health Insurance Fund was concluded in August 2018.

    • Recognition at Estonian Design Awards

      The PAIK project was recognised at the Estonian Design Awards. Life-changing service/solution: special mention of the work of PAIK/Viljandi Hospital, agency Velvet, authors: Krista Valdvee, Ander Ojandu, Andres Anier, Janno Siimar and Pärtel Vurma.
    • Description of service

      A description of the service was completed by the end of 2018.
    • Deed of the year 2018

      Piloting the PAIK project was named the deed of the year of Viljandi Hospital in 2018.
    • Assessment instruments

      The PAIK team has implemented a service criteria sheet, assessment instruments for assessing patients' condition and ability to manage as well as feedback questionnaires.
    • Family medicine centres in Teleskoop

      By spring 2020, half of all family medicine centres and all of the local governments of Viljandi County were integrated with the Teleskoop solution.
    • Home hospital

      The home hospital service was created due to COVID-19-induced external and internal needs. 


    Kadri Oras

    Head of the Home Services Department

    +372 5860 3169

    Eneli Tulp

    Health Manager

    tel 6000 151

    Merit Tekko

    Health Manager

    tel 6000 151

    Anu Välis

    Health Manager

    tel 6000 154


    Members of the PAIK team Mart Kull, Kristina Mätlik and Svea Seidla visiting Kuressaare Hospital in the summer of 2019.

    The PAIK project was recognised during the Estonian Design Awards in autumn 2018. The photo is of one of the authors, Krista Valdvee.

    The jovial and professional PAIK team during a team meeting.

    Kadri Oras, Head of the Home Services Department and the somatic department under PAIK, introducing the integrated services model to her colleagues.


    Cooperation day between primary level and local government social workers under the PAIK project in autumn 2019.

    Kadri Oras, the ever-positive Head of the Home Services Department, acquiring new information on the InterRAI assessment instrument in Belgium during an international InterRAI conference in 2020.

    Video conference of a patient's support team.

    Cheerful PAIK health managers en route to a home visit.

    Kadri introducing the new version of Teleskoop to the team.


    Team members of the PAIK project having a meeting in fresh air with lunch in spring 2020.


    Persons working together for the wellbeing of patients

    Viljandi County's

    • family physicians 
    • family nurses
    • local governments 
    Viljandi Hospital's

    • Home Services Department
    • Rehabilitation Departmen
    • Emergency Medicine and Internal Medicine Clinic
    • Surgery Clinic


    • Estonian Health Insurance Fund
    • Ministry of Social Affairs
    • TEHIK (Health and Welfare Information Systems Centre)

    Partnering up

    • Care coordination project
    • Stroke project of SA Tartu Ülikooli Kliinikum  (Tartu University Hospital)
    • Centre of Excellence on Dementia
    • IFIC - The International Foundation for Integrated Care