Whose Client: Yours, Mine, or Ours? Service Development for Frequent Attenders in 2021–2022
What defines a frequent attender? How can we better address their service needs? What constitutes multidisciplinary collaboration, and how is the coordination of service packages executed? From the client’s viewpoint, how do services currently present themselves, how should they be presented, and what outcomes are desired?
These are some of the questions we explored during the Frequent Attender project under the Future Health and Social Services Centres 2021–2022 Programme. The project aimed to develop a unified service concept to identify frequent attenders, assess multidisciplinary service needs, formulate a shared client plan, coordinate the client’s service package, and nurture multidisciplinary network collaboration.
This project focused on potential new clients as well as those already utilising the services. It is essential to support clients facing existing challenges while also identifying potential risks, mapping out currently utilised preventive measures, and determining how to avert individuals and families from becoming intensive service users.
Client Service Path
We began by examining the current service path of the frequent attender. From our discussions, it became evident that due to the complexity of the typical client’s situation combined with organisational intricacies, a single staff member may struggle to address the entirety of the client’s concerns.
For instance, the underlying cause of a client’s issue could remain undetected, which can manifest as an overdependence on services. This might also result in care, service, and rehabilitation plans that fail to consider the client’s inherent strengths and capabilities, thereby exacerbating the problems. The customer developers involved in the project stressed the importance of a holistic view of clients and families. More attention should be given to the coordination of services, and all communication—whether verbal or written—should be in language that is clear and comprehensible to the client. Moreover, clients should always know whom they can contact when needed.
Streamlining Services
Literature on the topic often highlights matters concerning the identification of frequent attenders and service needs. Within the Frequent Attender project group, a consensus emerged: while the importance of multidisciplinary collaboration is generally acknowledged, its enhancement requires specific models and tools. Efficient consultation practices and communication channels among professionals would improve collaboration. In contrast, factors that were identified to slow down this collaboration included issues with organisational structures, leadership challenges, unclear allocation of responsibilities, and the use of different information systems.
With these insights, we designed a service concept that considers the client’s situation as a whole. The tangible tools and outcomes of this endeavour included:
1. Description of the frequent attender’s current service path
2. Identification of bottlenecks in multidisciplinary collaboration
3. Description of the frequent attender’s ideal service path
4. Description of the shared client’s ideal service path, from the client's perspective
5. Description of the shared client’s ideal service path, from the professional's perspective
6. Criteria for identifying shared clients
7. A Checklist for identifying shared clients
8. Health and wellbeing indicators
Project Outcomes
Throughout the project, the term “frequent attender” often emerged in discussions. Particularly among customer developers, this term was perceived as overly organisation focused. In academic literature and national initiatives across other wellbeing services counties, the term “shared client” is frequently used. This term also became established during the development work of the Frequent Attender project.
Key areas pinpointed for further development encompassed the formulation of early intervention models centred around mapping early support methodologies and identifying points of intervention. These strategies would aim to prevent clients from becoming intensive service users. Additionally, a case manager-partner model was proposed, aiming to reduce repeated appointments and disruptive demands. Future pilot projects can fine-tune the service concept to better align with a diverse range of services.
The project clarified the service area’s perspective on which client demographics should be targeted for the development of a shared client model. Within the joint health and social services, two client groups were identified:
- Working-age clients of health centres who also have a need for social services.
- Adult clients of social services who also require mental health (and substance abuse) services.
Follow-up projects focusing on these two groups are now being initiated.
Further Collaboration
The project’s development was not a solitary endeavour. On the contrary, we embarked on it in collaboration with a wide range of stakeholders: a multidisciplinary project team, a customer developer team, social and healthcare professionals, representatives from disability councils, THL, and various organisations and companies. Furthermore, we cooperated with other teams working in projects under the Future Health and Social Services Centres Programme.
Our working methods included multidisciplinary teamwork, focused group work, customer developer sessions, workshops, client surveys, and, for the sub-projects (4), pilot testing. A heartfelt gratitude to all our contributors - our collective efforts and development of services for and alongside our clientele shall continue!
Further information:
Satu Meriläinen-Porras, Project Manager, Western Uusimaa Wellbeing Services County,
satu.merilainen-porras@luvn.fi