Involving social care workers in acute phase entails change in work processes.

Integrated care model’s implementation needs systemic approach in both systems.

For data exchange, interoperability between information systems must be secured.

The need to rethink regulative and operational factors on all levels for success.

Although strokes are one of the leading causes of death worldwide, their mortality is declining and the demand for integrated care is increasing. Therefore, changes in current health policy approaches are needed. In 2019, the Estonian Health Insurance Fund initiated a pilot study to examine an integrated health and social care approach in the journey of post-stroke patients. West Tallinn Central Hospital piloted the early involvement of community-based social care professionals of the local government. This research was conducted to examine the perceptions regarding an integrated care approach for post-stroke patients of all eleven participants via semi-structured in-depth interviews. By using a qualitative content analysis, participants’ experience with the selected approach were analyzed. The findings highlighted the potential and appropriateness of involving community-based social care professionals in the early phase of post-stroke management as part of a multidisciplinary team to enable a holistic, person-centered integrated care approach. The main challenges are the lack of different resources (e.g., specific knowledge, human resource, time), interoperability between health and social care electronic systems, and perceived inappropriateness in addressing a potential change in processes and with involved stakeholders. Thus, a comprehensive health policy and social care policy should be used to tackle these challenges to successfully implement an integrated care model with a multidisciplinary approach.

Stroke

Patient journey

Integrated care model

Person-centeredness

Estonia

© 2025 The Author(s). Published by Elsevier B.V.