hoitoketju

Hoitoketju is a concept used in Finnish health and social care to describe a coordinated, patient-centered care pathway that spans multiple providers and care settings. The aim is to ensure continuity of care from initial contact through assessment, treatment, and follow-up, across primary care, specialized care, and social services. The model emphasizes collaboration among health professionals, patients, and families to create a coherent plan that follows the individual’s needs.

The main purpose of a hoitoketju is to improve the continuity and quality of care, reduce delays and duplication, and enhance patient experiences and outcomes. It defines roles, responsibilities, and a sequence of actions, including timely assessment, care planning, delivery of treatment, appropriate discharge or transition, and ongoing follow-up. Successful implementation relies on shared information and standardized documentation to enable coordination across organizational boundaries.

Typical elements include a formal care plan, defined referral and triage processes, milestones or decision points, transition protocols between care settings, patient and family education, and regular review or update meetings. While hoitoketju concepts can be tailored to specific conditions or patient groups, common applications cover chronic disease management, post-acute rehabilitation, and transitions in elderly or frail care.

Implementation requires leadership and inter-organ collaboration, interoperable information systems, and agreed-upon practices for documentation and communication. Barriers can include fragmented services, information silos, and limited resources. Benefits are greater care continuity, smoother transitions, reduced hospital readmissions, and improved patient satisfaction. In Finland, hoitoketju is used as part of broader care coordination strategies, with guidelines and tools provided by health authorities to support local adaptation.