Blog Post

The Esther Model: How one patient redefined an entire system vision in Sweden

June 21, 2018

    This is the third blog in a series about care transformation around the globe, where we look at successful population health managers outside the United States. In this post, we highlight how a Swedish regional authority culturally aligned providers around care transformation.

    Poor coordination and the absence of clear cultural alignment are commonly cited barriers to care transformation. And from our research, it appears no country is immune to these challenges. However, Sweden's Esther Project is a great example of the power a patient story can have to facilitate cultural change, enable the creation a shared vision across the continuum, and ultimately, improve health outcomes.

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    In 1997, an elderly Swedish patient known as "Esther" arrived at her primary care provider experiencing shortness of breath. The GP decided she needed emergency care and called an ambulance. During her five-and-a-half hour journey through the system, Esther retold her story to 36 clinicians before she was admitted to the hospital and received treatment.

    This journey highlighted how patients often get lost in a system built around providers. With Esther's experience in mind, Jönköping County Council sought to fix their system's elderly, complex patient care—and the Esther Model was born.

    'What's best for Esther?'

    Over the next two years, a PCP-led team conducted interviews and workshops with providers to pinpoint care gaps and inefficiencies. They found that patients felt health care staff were too busy to listen to them and that the system was highly uncoordinated just like in the United States.

    To address these challenges, Jönköping County Council developed new care processes and the mantra, "What's best for Esther?" The new model elevated individual patients to the center of care decisions and culturally aligned providers around giving "Esther" the best care possible.

    Uniting providers under one vision

    To ensure cultural alignment, Jönköping developed four main avenues to bring providers together to co-design care transformation, including:

    1. Quarterly Esther cafés: Cross-sector patient experience meetings held to share stories from recently hospitalized patients;
    2. Yearly steering group: Committee of community care chiefs of municipalities, hospitals, and primary care who discuss challenges seen across organizations;
    3. Annual "strategy day": Nurses, doctors, coaches, and managers, come together for team-building exercises and to create a vision for the network; and
    4. Ongoing training: Inter-organizational education sessions on palliative care, nutrition, fall prevention, and other topics to facilitate collaboration and understanding.

    Notably, each meeting also involves at least one "Esther."

    Esther coaches drive front-line change

    In 2006, the network began training Esther Coaches to spread the initiative across the continuum and ensure continuous quality improvement. Nurses or allied health workers often volunteer for the role. To become a coach, they receive eight days of training in problem identification, quality improvement, and client focus. Coaches are responsible to promote front-line improvement projects, lean thinking, and positive psychology.

    In Jönköping, the Esther project has been tied to a 30% decrease in ED admissions (1998-2013) and a 9% decrease in 30-day readmissions for patients 65 and older (2012-2014).

    Based on this success, the model has gained attention and traction around the world. In Singapore, a regional health system began partnering with community organizations and PCPs to develop their own Esther network. In the UK, at least two systems have adopted Esther cafés to train staff and align everyone around the same vision.

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