järgitavust
Järgitavust is an Estonian term describing a set of aftercare services designed to support individuals following an initial intervention, such as hospital discharge, completion of a rehabilitation program, or a social welfare service. The aim is to ensure continuity of care, prevent deterioration, and promote independence. Järgitavust typically includes planning and coordination of ongoing care, follow-up contacts, home visits when needed, medication management, rehabilitation activities, mental health support, and assistance with daily living tasks or social reintegration. It is often delivered by a multidisciplinary team including physicians, nurses, social workers, therapists, and user organizations, and may involve primary care clinics, municipal health centers, or home care services.
Delivery models vary but commonly involve discharge planning, case management, and scheduled follow-up visits or telehealth
Over several years, emphasis has grown on transitional care to reduce hospital readmissions and support patient-centered
See also: aftercare, discharge planning, transitional care, case management.