Pirkanmaa doctors will call chronic patients before their conditions worsen

Doctors and nurses in Finland’s Pirkanmaa wellbeing services county are beginning a trial in which they contact chronic patients before those patients book an appointment, Yle reports. The aim is to address problems with treatment early and reduce emergency visits and lengthy hospital stays.

The trial began in September at five healthcare centres, with 20 doctors taking part. They plan to call about 200 patients by the end of the year. The first calls were made on September 17, and around 10 had been made by early October.

Doctors will search the Kanta health records archive for information about patients on their own lists. The results are analysed using a health benefit assessment tool developed by Duodecim, which identifies patients whose treatment may need attention. The review can focus on conditions such as high blood pressure.

New legislation allows a doctor to use Kanta information when they have an active care relationship with the patient. Only the patient’s own doctor may view the information. Records from private healthcare, for example, may not appear in public healthcare records but can be found in Kanta.

If a patient only needs a medication adjustment, the issue can often be handled during a phone call. For more complex needs, a nurse may call and invite the patient to an appointment. The outreach may also concern chronic conditions for which required laboratory tests have not been done.

Pirkanmaa development doctor Riku Metsälä said the approach could help prevent treatment from becoming unstable and leading to costly emergency care or inpatient treatment. He expects preventive calls to become at least partly established in primary care and said other wellbeing services counties are also considering similar work.