The International Foundation for Integrated Care (IFIC) has led the redesign of a multi-layer care pathway for older adults in Europe in the framework of the PROCare4Life project. Specific to this project, “the purpose of the care pathway planning is to produce a written document that records needs, identifies actions to be taken, and resources that need to be put in place to support participants to use PROCare4Life” as part of Work Package 3 of the project Grant Agreement.
Thus, the pathway representation for participants, clinical partners, and stakeholders includes a consolidation of clinical partners’ individual pathways, a multi-actor needs pathway, and a project pilot specific pathway delineating assessments and time. The integrated care pathway is framed through the person-centred lens, a life-course trajectory, and the integrated care quadruple aim. Creating this care pathway leads to knowledge-based care planning, facilitates coordination, and fosters multi-stakeholder involvement through referral to psycho-social support services and community links.
The evolution of PROCare4Life’s care pathway began with each clinical partner’s general pathway: admission, assessments, treatments, and discharge. By adding the participant and system perspectives, the pathway then incorporates other steps such as access, maintenance, care plan revision, re-assessments, community support services, and palliative and end of life care. The illustration of links amongst and the overlapping of elements within the pathway, highlight potential stakeholder collaboration. Furthermore, the coordination factor becomes relevant in guiding and sustaining communication and movement across the pathway.