Streamlining Healthcare: The Role of Care Pathways
Defining what a care pathway is (and isn't)
While there is considerable variation in definition and application between concepts such as care pathways, guidelines and practice frameworks, the intent is largely consistent across each of these terms — to synthesise the best available evidence about what care a person experiencing a condition should receive and how, and make this available to relevant stakeholders. This might include clinicians, consumers and carers, and those commissioning health services consumers, to improve service navigation, coordination and decision-making.
Some of the key terms we often use are:
Care pathway — A representation of services and supports that should be available and accessible to a person experiencing a particular condition, including how these services are connected and coordinated within a defined 'system of care'.
System of care — A broad, flexible mix of services and supports defined by a geographical boundary and/or other factors that are organised into a coordinated and integrated network.
Pathway product — The tangible output used to present a care pathway tailored for a specific audience group, such as a visual guide, interactive tool or information resource.
Service — A formalised service or program with a direct or indirect aim of improving outcomes for a person with a given condition.
Support — Informal or natural supports that benefit a person with a mental health condition, such as family, friends, unpaid caregivers and other relationships within their community.
The rationale and evidence for care pathway development
The variability in defining what a care pathway is and how it should look means that the availability of evidence to demonstrate their effectiveness in improving health system outcomes is limited. Most evaluations of care pathway outcomes have occurred around clinical-only pathways within hospital settings. The evidence base around more holistic pathways of multidisciplinary services and community-based supports is quite limited, but there is some evidence suggesting a positive impact on quality and safety, better consumer experiences of care, and better coordination and integration of services and supports.
While the evidence may be limited, the rationale for the development of System of Care Pathways makes complete sense based on the potential to address those common and 'sticky' health system challenges that impact the pathways that people and communities have to experience (and endure) to get their needs met, such as:
taking the best available evidence and translating it at a local level to guide multidisciplinary care planning and work processes,
addressing inequities and variation between what the evidence says people should receive versus what is actually available for people to access,
ensuring the design of new/expanded services, use of intake/assessment processes and development of referral/connection pathways is informed by good evidence.
Agreeing and documenting the 'optimal' care pathway for someone experiencing a given situation/condition/need is an important first step in changing how services and systems work together to provide that optimal pathway.
In a practical sense, care pathway development has generally aimed to describe and define what the consumer journey should look like — this forms a rights-based and health equity approach. Through a person-centred lens, this should span various organisational and sector boundaries to define what a person can and should expect.
Care pathway 'products' should then seek to guide and prompt health professionals and commissioning bodies in the decisions they make, while also allowing scope for tailoring to local contexts, updating as new evidence emerges about 'what works', and practitioners to apply their professional judgement and consumers to self-determine how they meet their needs.
How to develop care pathways
In coming up with a stepped approach to developing care pathways or similar resources that can enable better navigation of health services and systems, we've drawn on evidence around the ‘guidelines for guidelines’, including the recommended components and process steps in ensuring tools such as care pathways are most effective.
Their guidance highlights the need for setting priorities based on identified needs, establishing advice and consultation processes, sourcing and synthesising evidence about what works, integrating consumer perspectives and other considerations (e.g. equity, resourcing), and then planning methods or 'products' for disseminating pathway information to various audiences with a specific purpose or objective in mind.
From our perspective, the process of developing relevant, practical and agreed care pathways involves:
Step 1: Establishing an expert advisory group who are jointly responsible for developing, endorsing and reviewing the local system of care pathway, with representation from relevant stakeholders with both professional and lived expertise — the establishment of such a group often requires a suitable lead agency, clear expectations about the purpose and scope of the group, and the need to manage conflicts of interest and divergence in views.
Step 2: Defining research questions that provide scope and focus to the 'issue' being considered in the pathway — this helps to guide the selection of evidence-based materials and resources that will be used to understand what optimal care looks like, and explore the areas relevant to the system of care (e.g. types of services/supports, models of delivery, coordination, workforce, populations, outcomes).
Step 3: Undertaking a review of the evidence through gathering, evaluating and extracting information from credible sources to identify guidelines and recommendations for what the optimal system of care looks like for the situation/condition/issue being explored.
Step 4: Identifying and profiling the services and supports that are currently available for people within a defined area and for the specific situation/issue/condition — this seeks to capture information about the current state of these services and supports in terms of their availability, accessibility, responsiveness, capability, acceptability, quality and effectiveness.
Step 5: Understanding local service experiences and perceptions from the perspective of consumers of services, people with lived experience of the situation/condition being explored and local practitioners/clinicians involved in the local system of care — this is a critical step in integrating these values, priorities and understanding about what's happening currently into the development of any optimal care pathway.
Step 6: Develop an agreed, locally relevant system of care pathway that represents the agreed mix of services and supports that are supported by good evidence as being beneficial to a person experiencing the situation/issue/condition of interest that should be available to them — often this pathway will apply the principles of 'journey mapping', where it is represented as a time-based and logical flow of the services and supports that a person may access without it being a strict linear process.
Step 7: Develop and distribute pathway products that translate the agreed system of care into products that make the information available to end users in the most engaging and usable format — the type of products that might be suitable will depend largely on a user's role or perspective within the pathway and how they might prefer to receive and use information. This should include planned methods of dissemination, implementation support and ongoing review.
Across each of these steps are several enablers that lead to better outcomes, such as:
direct involvement of experts
care pathways being connected to consumer information, clinical/provider education and service/system commissioning and improvement activities
technology and information systems support the flow of information
sustainable resourcing to support the pathway
shared whole-of-pathway governance and accountability.
Profiling some examples of care pathway products
Example 1: Eating disorders system of care pathway, My Mental Health
Our team has previously worked closely with Brisbane North PHN and Eating Disorders Queensland to develop a system of care pathway for eating disorders in the Brisbane North region.
The pathway describes the types of services and supports that may benefit someone with an eating disorder at various stages along their journey. It also describes what people can expect from each type of service or support, and how they can access relevant and credible services and resources. The pathway is a digital product hosted on the Brisbane North PHN's existing My Mental Health portal and allows users to 'drill down' into a considerable level of detailed information based on the part of the pathway they're interested in.
In this way, the product aims to build health literacy of people with an eating disorder, as well as carers, key supports and health professionals supporting someone with an eating disorder.
Example 2: Optimal care pathways for cancer
Cancer Council Victoria, in partnership with a range of other organisations, has developed a suite of Optimal Care Pathways that provide a framework for the delivery of consistent, safe, high-quality, and evidence-based care for people with cancer. This type of pathway is more clinically oriented, outlining the optimal pathway at quite a detailed level including detection, diagnosis, tests, treatment, recovery and survivorship.
The pathways are provided in multiple product formats and uses, including detailed guidance for health practitioners, shorter summary 'best cancer care' guidances and an interactive web app.
Tips for developing a care pathway
We've been fortunate to work with a range of organisations to support the development of care pathways or similar service navigation products in different contexts— including Primary Health Networks (PHNs) in their planning and commissioning role, and with non-government organisations (NGOs) who deliver services and supports as part of a system of care.
Here are some of the process learnings we've identified that might help other organisations develop care pathways that contribute to better service navigation and system integration:
Not all care pathways are created equal (or even that similar) — they vary considerably in their purpose/problem, intended audience, depth/detail, format and information fields. Understanding why a care pathway might be helpful in a given context is crucial to determining what it should look like.
Keeping the development and agreement on the pathway separate from the development of products that communicate that pathway to various users in meaningful and engaging ways is important to maintain to avoid confusion for stakeholders who are stepping in and out of the process along the way.
Some span the entire 'system' with all the possible services and supports that may be of benefit, while others focus more narrowly on specific parts of the pathway — making explicit what's in and out of scope is an important step for you to do collectively with your stakeholders to manage expectations and avoid an over-collection and/or over-supply of information.
Care pathways products often have a lot of detailed information that needs to be balanced by making it easy to consume and navigate — the most effective products include an overarching (often visual) hierarchy of information that illustrates the overall mix and sequence of services and supports, and then offer the ability to ‘drill down’ into more detail so people can get the information they need in right-sized chunks.
Articulating the underlying principles, policies/strategies and performance standards that are relevant to the pathway provides an important point of reference to return to in detailed conversations about what's important and what's not — for example, the principle of a rights-based approach would focus on a pathway that highlights what should be in place even if that's not what's currently available.
Products for consumers and their carers often contain information about what specific services and supports are available, what the expected user experience might be, where the service is available, and how it can be accessed which are often referred to as 'service directories' — these can be a helpful product, but shouldn't be the main game.
Using a systematic process with good project management principles is important to support role clarity and set expectations for when and how various stakeholders will contribute to the development of the pathway.
Seeing care pathway development as a key tool for developing health literacy, rather than a superficial exercise of simply listing existing services will mean these products have wider benefits — this might be ease of navigation for people accessing services, clinicians being able to deliver services and make referrals that align with evidence-based care, and organisations across the system coming together to undertake quality improvement activities and commissioning services to fill gaps.
Technology and digital products create a valuable opportunity to produce care pathway products in a format that is reasonably inexpensive, is easily accessed by most people within the community, creates an interactive user experience, can be widely distributed and is easy to update as needed.
Having an identified lead agency who brings process knowledge and the skills to facilitate a collaborative process with the range of expert stakeholders required through co-design principles is critical to adequately and capably resource the work required.
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