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

March 13, 2017

    In 1997, an elderly Swedish patient known as "Esther" arrived at her general practitioner (GP) 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 a more pressing problem than just the glaring inefficiencies present across the continuum. Esther found herself lost in a system built around the provider, not the patient. With Esther's experience in mind, Jönköping County Council sought to fix their system's elderly, complex patient care—and thus the Esther Model was born.

    "What's best for Esther?"

    Over the next two years, a GP-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 too many providers were involved in their care. The analysis also uncovered how uncoordinated the system was—it was full of redundancies, inefficiencies, and variation.

    To address these challenges, they developed new care processes and the mantra, "What's best for Esther?" The new model elevated individual patients to the centre of care decisions and coordinated providers by aligning them around giving "Esther" the best care possible.

    Uniting providers under one vision

    To reduce fragmentation and increase coordination, Jönköping developed multiple avenues to bring providers together to co-design a system vision while ensuring individual Esthers remained central to their work. They focused on four streams of work:

    1. Quarterly Esther cafés: Cross-sector patient experience meetings held to share stories from recently hospitalised patients

    2. Yearly steering group: Committee of community care chiefs of municipalities, hospitals, and primary care who discuss challenges seen across organisations

    3. Annual "strategy day": Nurses, doctors, coaches, managers, and Esthers come together for team-building exercises and to create a vision for the network

    4. Ongoing training: Inter-organisational education sessions on palliative care, nutrition, fall prevention, and other topics to facilitate collaboration and understanding

    This model and meeting format emphasise that this is truly a network of providers that are equals in care provision. Most importantly, each meeting involves at least one Esther to guarantee that the patient's experience is always included.

    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. Coaches, usually nurses or allied health workers, are not paid for this commitment—rather, their extra work is seen as part of their jobs. To become a coach, they receive eight days of training in problem identification, quality improvement, and client focus.

    In their respective organisations, coaches are responsible for using this training to promote front-line improvement projects, lean thinking, and positive psychology in addition to their normal workload. And just like the cross-continuum meetings, every training session must have an Esther in the room.

    Results and international adoption

    In Jönköping, the Esther project has been tied to a 30% decrease in ED admissions between 1998 and 2013, as well as a 9% decrease in 30-day readmissions for patients 65 and older between 2012 and 2014. Based on this success, the model has gained attention and traction around the world.

    In Singapore, SingHealth Regional Health System began partnering with community organisations and GPs in 2016 to develop their own Esther network. They now have 60 ambassadors from the hospital, community, and primary care leading the project.

    We also saw Esther expand to two systems in the UK in 2016. In South Somerset, the same Esthers attend cafés every other quarter to report on progress they have seen. In Kent, they are expanding upon the model by offering cafés every two months, and training care workers, social assistants, chefs, and maintenance workers to be a part of their vision.

    By organising health care around individual patient needs, these regions are overcoming fragmentation and transforming care throughout their entire system. But more impressively, they are able to improve care for Esthers every step of the way.

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