Nationwide Digital Integrated Care Plan for Coordinated Health and Social Services - An Estonian Example

Ageing populations and multimorbidity highlight the limitations of siloed, disease-centered services. Despite Estonia's highly digitalized healthcare system, integration between health and social care remains challenging, leaving individuals with complex needs without sufficient support. Based on international experience, the Estonian context, and multi-stakeholder focus groups, we identified key challenges and opportunities for implementing a consent-aware, interoperable Digital Integrated Care Plan (DICP). A DICP can enable shared understanding among professionals and ensure continuity of care across hospitals, primary care, and social services.