Start Submission Become a Reviewer

Reading: Identifying the individuals who might benefit from integrated care: The case of Finland


A- A+
Alt. Display

Conference Abstracts

Identifying the individuals who might benefit from integrated care: The case of Finland


Juha Koivisto ,

National Institute For Health and Welfare, Finland, FI
X close

Hanna Tiirinki,

X close

Eeva Liukko,

X close

Laura Hietapakka,

X close

Timo Sinervo

X close



In Finland and in several other countries about 10 % of the users of health and social services use plenty of services within one or several sectors and produce about 80 % of its costs. The individuals with several health and/or social problems should be identified as early as possible and offer them support and integrated care to avoid human suffering and the uncontrolled grow of the costs of care. This study mapped and examined the models and tools which are in use or under development in Finland to identify the potential individuals who might benefit from integrated care.


The models and tools were examined in the health and social care organisations by a survey (n=499) in spring 2019 and by supplementary thematic interviews (n=5) in spring 2020.


In Finland only a third of the health and social care organisations have an established model for identifying individuals for integrated care. There are three main approaches for identification: 1) the individuals are most commonly identified in an initial interview or service needs assessment and when guiding the clients to different services; 2) information systems are used when segmenting and identifying the clients; 3) identifying occurs in different models of professional collaboration when the needs of clients are assessed more closely for example by multidisciplinary and paired teams or by case managers who are responsible for coordinating referrals and services.


The identification of individuals for integrated care is insufficient and unsystematic in Finland. It is hampered by the inadequate development of client and patient information systems, disjointed operating cultures, and the lack or inadequacy of established models. There is too much responsibility on individual professionals to identify the individuals and refer them to appropriate services. However, a variety of the good practices of identification are being developed in a number of different organizations. Nationally comprehensive training for and implementation of models and tools should be enacted in health and social care.


The models should be able to identify individuals who are outside the service system, those whose clientship has just started, and those who already access services. This requires the use of individual level data from information systems, but also other approaches, such as outreach and interactive work with clients and patients. Identification should be an integral part of the work processes and their phases.

Lessons learnt

Nationally agreed and convergent approaches are required in some aspects so that they can provide joined-up and measurable data on specific demographics, issues and diseases and also support the evidence base for monitoring, steering and peer-development purposes.


The analysis of the models in Finland is narrow basing only on a survey and limited number of interviews

Suggestions for future research

The future research could study in a deeper level the workability – the pros and cons – of the identification practices as an initial part of the whole service processes and chains.

How to Cite: Koivisto J, Tiirinki H, Liukko E, Hietapakka L, Sinervo T. Identifying the individuals who might benefit from integrated care: The case of Finland. International Journal of Integrated Care. 2022;22(S1):21. DOI:
Published on 08 Apr 2022.


  • PDF (EN)