Paljon palveluja tarvitsevien asiakkaiden yksilöity sosiaali- ja terveyspalvelujen yhteen kokoaminen

The purpose of this study was to describe and understand the individualised integration of social and health services for frequent attenders by customer profile from the perspective of knowledgebased management. The study was carried out using the multi-method approach. Sub-study (I) described what kind of customer profiles could be identified among municipal residents based on diaries (n=15) at the planning stage of the social and health care centre. Sub-study (II) identified the customer profiles of frequent attenders based on service plans (n=56). Sub-study (III) described, in the form of a register study, based on four customer profiles, the use of primary healthcare, emergency care and specialised healthcare services by frequent attenders (n=2388) and the social services decided to them. The data of the sub-studies was analysed by means of content analysis and systematic analysis as well as statistically. As a result of the study, customer profiles were generated both for municipal residents and for frequent attenders. The purpose of identifying customer profiles for municipal residents was to seek preunderstanding for the definition of frequent attenders’ customer profiles. With frequent attenders, physical, mental and social service needs are intertwined. The use of social and health services was highly individualised according to the customers’ current life situation. The study highlighted from the perspective of knowledge-based management the need for individualised integration of social and health services for frequent attenders and for the multidisciplinary social and health information and the flow of information between different social and health service operators it requires. The results of the study can be utilised in the construction and management of the integration of social and health services for frequent attenders.