How can we ensure that individuals with complex care needs receive timely, coordinated, and person-centered support? It’s a question that sits at the heart of modern healthcare and social care — especially in regions where resources are stretched and coordination between systems is often lacking.
At Kodality, we specialize in developing mission-critical IT solutions that bridge gaps in care. Our latest project focuses on the Care Coordination Service (Hoolduskoordinatsiooni teenus) — a digital backbone designed to support care coordinators (tervisejuhid) in guiding people through their health and social care journeys smoothly and without disruption.
Our goal? To understand real-life care delivery challenges and translate those insights into a practical, human-focused digital service that makes a difference where it matters most.
As part of the groundwork, we conducted an in-depth analysis in collaboration with key partners: Ida-Viru Central Hospital, Association of Local Authorities of Ida-Viru County, Narva Hospital, Viljandi Hospital, and the Ministry of Social Affairs. The analysis was developed under the Just Transition Fund measure “Development of Social and Health Services Supporting Societal Change in Ida-Virumaa” (Ühiskondlikku muutust toetavate sotsiaal- ja tervishoiuteenuste arendamine Ida-Virumaal).
Why Does It Matter?
People with complex care needs often require support from multiple service providers, increasing the risk of fragmented care, communication gaps and inefficiencies. The Care Coordination Service will empower care coordinators to manage cases more effectively, ensuring that services are:
- Efficient – Reducing communication breakdowns between healthcare and social care providers.
- Well-structured – Enabling systematic documentation and clear responsibility management.
- Person-centered – Ensuring the individual’s needs are at the heart of every decision.
By tailoring the system to the specific needs of care coordinators, we aim to enhance collaboration, streamline workflows, and improve outcomes for individuals requiring complex care services.
Building a Strong Foundation: A Structured Approach
To ensure the solution is flexible, scalable, and fit for purpose, we conducted a comprehensive analysis that now serves as the foundation for system development. This analysis covered four key areas:
- Use Cases & Scenarios – Mapping real-life care coordination scenarios to define the system's core requirements, ensuring it supports the day-to-day work of care coordinators.
- Functional Requirements – Defining the system’s core capabilities based on real-world use cases, forming the foundation for technical specifications.
- Non-Functional Requirements – Aligning the system with national IT infrastructure and ensuring compliance with national e-health standards.
Kodality’s Role: Delivering a Future-Ready Solution
Our extensive experience in healthcare IT development and practical insights of our partners created a synergy to approach this project with strategic foresight and precision:
- Use Case Analysis & Stakeholder Collaboration – We facilitated structured discussions to refine use cases, ensuring the system meets the practical needs of care coordinators and integrates seamlessly with existing workflows.
- Technical Specifications & System Requirements – We developed a comprehensive framework to guide software development, ensuring the solution is scalable, adaptable, and future-proof.
- FHIR-Based Interoperability – Leveraging our expertise in FHIR model development, we ensured the solution enables standards-compliant data exchange with healthcare systems.
- Compliance & IT Infrastructure Alignment – We ensured all developments align with national e-health requirements and data protection standards.
What’s Next?
With the analytical groundwork complete, the project is transitioning to the development phase, where the insights will be transformed into a fully functional Care Coordination Service aimed to deliver a system that empowers care coordinators to provide better, faster, and reliable services — ultimately improving outcomes for individuals requiring complex care.
This project has been financed by the European Union.
