Paljon palveluja tarvitsevien asiakkaiden yksilöity sosiaali- ja terveyspalvelujen yhteen kokoaminen

Abstract The purpose of this study was to describe and understand the individualised integration of social and health services for frequent attenders by customer profile from the perspective of knowledge-based management. The study was carried out using the multi-method approach. Sub-study (Ⅰ) described what kind of customer profiles could be identified among municipal residents based on diaries (n=15) at the planning stage of the social and health care centre. Sub-study (Ⅱ) identified the customer profiles of frequent attenders based on service plans (n=56). Sub-study (Ⅲ) described, in the form of a register study, based on four customer profiles, the use of primary healthcare, emergency care and specialised healthcare services by frequent attenders (n=2388) and the social services decided to them. The data of the sub-studies was analysed by means of content analysis and systematic analysis as well as statistically. As a result of the study, customer profiles were generated both for municipal residents and for frequent attenders. The purpose of identifying customer profiles for municipal residents was to seek preunderstanding for the definition of frequent attenders’ customer profiles. With frequent attenders, physical, mental and social service needs are intertwined. The use of social and health services was highly individualised according to the customers’ current life situation. The study highlighted from the perspective of knowledge-based management the need for individualised integration of social and health services for frequent attenders and for the multi-disciplinary social and health information and the flow of information between different social and health service operators it requires. The results of the study can be utilised in the construction and management of the integration of social and health services for frequent attenders.Tiivistelmä Tutkimuksen tarkoituksena oli kuvailla ja ymmärtää paljon palveluja tarvitsevien asiakkaiden yksilöityä sosiaali- ja terveyspalvelujen (sote) integraatiota asiakasprofiileittain tietoperustaisen johtamisen näkökulmasta. Tutkimus toteutettiin monimenetelmäisesti. Osatutkimus (Ⅰ) kuvasi, millaisia kuntalaisten asiakasprofiileja oli tunnistettavissa päiväkirjojen (n = 15) avulla hyvinvointikeskuksen suunnitteluvaiheessa. Osatutkimuksessa (Ⅱ) palvelusuunnitelmien (n = 56) perusteella tunnistettiin paljon palveluja tarvitsevien asiakasprofiileja. Osatutkimuksessa (Ⅲ) kuvailtiin rekisteritutkimuksena neljään asiakasprofiiliin perustuen paljon palveluja tarvitsevien asiakkaiden perusterveydenhuollon, päivystyksen ja erikoissairaanhoidon palvelujen käyttöä (n = 2 388) sekä heille myönnettyjä sosiaalipalveluja. Osatutkimusten aineistot analysoitiin sisällönanalyysillä, systemaattisella analyysillä sekä tilastollisesti. Tutkimuksen tuloksena syntyi sekä kuntalaisten että paljon palveluja tarvitsevien asiakkaiden asiakasprofiileja. Kuntalaisten asiakasprofiilien tunnistamisella haettiin esiymmärrystä paljon palveluja tarvitsevien asiakkaiden asiakasprofiilien määrittelyyn. Paljon palveluja tarvitsevilla asiakkailla fyysiset, psyykkiset ja sosiaaliset palvelutarpeet kietoutuivat toisiinsa. Sote-palvelujen käyttö oli vahvasti yksilöity asiakkaiden oman elämäntilanteen mukaan. Tutkimus nosti esille tietoperustaisen johtamisen näkökulmasta perusteen paljon palveluja tarvitsevien asiakkaiden yksilöityyn sosiaali- ja terveyspalvelujen yhteen kokoamiseen ja sen edellyttämään monialaiseen sote-tietoon ja tiedon liikkumiseen eri sote-toimijoiden välillä. Tutkimuksen tuloksia voidaan hyödyntää paljon palveluja tarvitsevien asiakkaiden sote-integraation rakentamisessa ja johtamisessa

Profiling frequent attenders to social and health care services from the perspective of knowledge-based management

Abstract Background: Identifying of frequent attenders has been a focus of research in health care for decades. Profiling frequent attenders from the perspective of joint service planning and knowledge-based management in social and health care services has not been previously studied. Objective: To profile frequent attenders to social and health care services from the perspective of knowledgebased management. Methods: The informants in this study were customers of different ages (n=56) who required the services of social and healthcare centres. The qualitative method used for analysing the service plan was the systematic analysis. Results: Four customer profiles were classified, one for children and adolescents: Children and adolescents who are burdened by everyday concerns. The other three profiles were for adults: Mothers requiring support, Customers with multiple problems, Customers with an impaired capacity caused by substance abuse. In each of the profiles, physical, mental health and social problems were interlinked and customers had a need for multiprofessional and customised social and health care services to support their daily lives. Conclusions: There is a need for an improved understanding of the different customer profiles of frequent attenders and knowledge about the social and health care services they use, as well as for mediating this knowledge across professional barriers and knowledge-based management. Defining customer profiles may help identify frequent customers who require multiprofessional social and healthcare services in order to develop effective care and services

Individualised integration of social and health services for frequent attenders

Abstract Purpose: The purpose of this paper is to describe how frequent attenders (FAs), divided into different profiles, use of primary care, emergency care and specialised medical care and which social services have been granted to them. Design/methodology/approach: The present study utilises previous research of FAs and their identification of four profiles. The data were acquired from three data registries in Finland. Analysis of the FAs (n = 56) data was undertaken using descriptive statistics methods and qualitative analysis. Findings: Patients with multiple problems used primary care, emergency care and specialized medical care frequently, and they had the highest number of appointments with doctors and nurses. Social services were required mostly social work. Visits made by patients with an impaired capacity caused by substance abuse were mainly targeted at appointments and mental health care services to a nurse in primary care. The required types of social services were often rehabilitative work experience. For mothers requiring support, the most frequently used services in primary were the child health and maternity clinic. The social services granted were mostly social work. Children and adolescents who are burdened by everyday concerns visits were mainly focused on primary to the child health and maternity clinic. Use of social services often entailed the supervision of contact sessions between parents and children’s. Research limitations/implications: The study confirmed that there is a need for increase knowledge of FAs. The service needs of FAs should be understood multi-dimensionally and the research results justify the individualised integration of social and health services for FAs. Originality/value: The research results justify the individualised integration of social and health services for FAs