Frequent and recurring patients

Purpose and goal

The project´s aim is to manage the growing group of patients with frequent and recurring needs that generate many unplanned contacts and burden acute flows. The main goal is to conduct a pilot with several healthcare actors to introduce a system-wide collaboration model. This model will provide the patient with a designated nurse contact and a common care plan. Sub-goal: 50% fewer unplanned calls/visits in the target group, increase patient safety, continuity and achieve resource optimization.

Expected effects and result

The project is expected to result in 50% fewer unplanned calls/visits in the target group. The primary effects are increased patient safety and continuity as well as resource optimization through controlled overlap and close collaboration with primary care and municipal care. The project will be spread regionally and nationally. This contributes to SustainGov´s mission through proactive, individual-oriented governance that frees up capacity and strengthens trust in healthcare.

Planned approach and implementation

The project is an implementation project (2025-11-10 to 2027-11-30) that is conducting a pilot in Region Västmanland. The approach focuses on introducing a system-wide collaboration model between parties such as the Medical Dispatch center/ambulance, 1177, emergency department, primary care (Praktikertjänst Fagersta) and Fagersta municipality. The implementation means that patients receive a designated nurse contact and a common care plan. The model can be spread regionally and nationally.