Estonia to scrap social rehabilitation service, reorganize under healthcare | News

According to state figures, a total of 10,688 people received social rehabilitation services in 2022, 61 percent of whom were children, at a total cost to the state of just over €16 million.

Providers of social rehabilitation services include social workers, psychologists, physical therapists, speech therapists, special education teachers as well as occupational, music and creative arts therapists.

The ministry believes, however, that there are several issues with the current provision of social rehabilitation – one of which is the fact that the same specialists are providing services via multiple different systems, sometimes in duplicate. A child could thus end up receiving services from a speech therapist or psychologist via school, their family doctor as well as via the state’s social rehabilitation service. Separate work-related rehabilitation exists as well.

In other words, from the patient’s perspective, their care pathway is unclear, and depends on where they end up turning first for help.

Kristi Kähär, support and services protection adviser at the Estonian Chamber of People with Disabilities (EPIK), agrees that the current system is illogical and and burdensome for patients.

“Let’s take a disabled child, for example, who should receive speech therapy in school, but doesn’t,” Kähär described. “Their parent may then contact their family doctor instead, who has [access to the] therapy fund through which to refer them to a speech therapist. And the third option is social rehabilitation as well, but that is a bundled service. In that case, the person must have a need for multiple services, and there are plenty of cases where someone has been designated social rehabilitation services even though they only actually need a speech therapist, not a speech therapist, special education teacher as well as a psychologist.”

This unclear and at times duplicative rehabilitation system has also led to difficulties in the exchange of necessary data as well.

Association of Estonian Rehabilitation Institutions (ERL) board chair Marilin Vaksman explained that because rehabilitation institutions aren’t currently legally considered healthcare providers, they lack access to the Health Portal (terviseportaal), the centralized record gateway formerly known as digilugu, and don’t have a clear overview of what other services a patient has received elsewhere.

“There’s no unified system, and even now, family doctors may be unaware that someone is [receiving rehabilitation services],” Vaksman said. “If they don’t mention it themselves, then it doesn’t turn up anywhere.”

The Social Affairs Ministry cites in its legislative intent the concern that a patient and their loved ones have to shuffle their records from office to office, either on paper or as digital files, as well as the fact that there is no way for them to look up digitally what services and in what volumes they are eligible to receive.

Referrals to occupational therapy, speech

In order to provide patients with clear and logical assistance, the Ministry of Social Affairs finds that services should be organized via the healthcare system instead.

The ministry is proposing increasing the volume of healthcare services with the current rehabilitation services budget, including current healthcare services such as physical therapy, speech therapy and psychological care.

The state believes that a healthcare worker such as a family doctor or medical specialist should assess what kind of help a patient needs, and then refer them to the appropriate specialist. This means that on top of diagnosing the patient, the healthcare worker would also describe the help they need.

“Speech therapists, clinical psychologists and physical therapists were added to the list of healthcare service providers in October already; medical specialists can already refer them to these specialists as well,” said Brit Tammiste, head of policy for children with special needs at the Ministry of Social Affairs. “It doesn’t necessarily have to go through your family doctor.”

Unnecessary services being provided

Estonia’s current social rehabilitation service is a bundled service, meaning that a patient’s social rehabilitation team consists of at least three specialists providing the patient with care.

Tammiste explained that at present, rehabilitation institutions assess for themselves what services and in what volumes patients need.

What services are provided to specific target groups, such as children or people with mental health issues, is currently not standardized, she acknowledged. Meaning that currently, rehabilitation institutions can offer patients services they don’t necessarily need as part of their bundled care plan.

“At present, if there’s someone with a specific health need, for example, then it’s unspecified what should be done with them in rehabilitation services from an evidence-based perspective,” Tammiste said. “In other words, if someone sees one or another service provider, then right now, the content of the services offered varies and may not directly meet the person’s needs.”

She acknowledged that there is currently a lot of arbitrariness to the provision of social rehabilitation services, and that the effectiveness of these services currently isn’t assessed either.

“In the future, we want services’ effectiveness to be assessed as well,” the official added.

Disability status requirement to be dropped

While some patients may be receiving bundled services from several specialists on the state’s dime, even if they only actually require the care of one specific specialist, the reverse is currently possible as well.

Unable to access Estonia’s social rehabilitation service as currently organized, for example, are children and adults with no determined disability status but who nonetheless need help.

“Sometimes, as a result of trauma from an accident or illness, the need for rehabilitation may be temporary as well,” ERL board chair Marilin Vaksman said. “Then this person could get the help they need right away, without having to apply for disability first, because that takes time to process. A person can get help for just half a year, after which they can return to work already or they begin to do significantly better.”

According to the state’s plans, in the future, a person’s disability status or lack thereof would no longer be a decisive factor, and services would be available to everyone who needs them.

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