Vertical and horizontal administrative integration brought by the ongoing Health and Social Care Reform is expected to ensure that people who need integrated services are identified, their service and care chains and packages are defined, health and social welfare services are coordinated with other services provided by municipalities (for example, education, unemployment services), and information about clients exchanged between different providers. In addition, there are recommendations based on the national Care Guidelines (Nuutinen, 2017) and adapted at the county level, that address integration of primary and secondary levels of care, and outline patient pathways.
Despite these efforts, a lack of continuity of care between different parts of the system remains. A specific bottleneck is the point of discharge from hospital care for patients who no longer need specialist care but lack suitable follow-up care at their place of residence. Consequently, in some health authorities, dedicated teams of nurses, coordinated by a primary care physician, have been established to ensure patients’ safe return home. These teams can also include physiotherapist and occupational therapist, and the follow up may include a short intensive home rehabilitation period.