Developing care pathways

Working together with people with long term conditions to co-design care pathways is the most effective way to develop services that support and enable people to self-manage.

Some approaches to developing care pathways so they better support self-management include:

  • Identify the points in the care pathway where people might be referred into training in self-managing their condition.  Working with people with long term conditions can help you to identify both potential referral points and the referral process that is most likely to be effective.  You can then build ‘triggers’ into the pathway that prompt clinicians to refer people. 
    For example, the self-management support team in Ayrshire & Arran are working with colleagues in primary care to improve referral systems:

    “We’re looking at that just now – how systematically people are referred to Pulmonary Rehabilitation, because it does rely on clinicians – GPs, practice nurses, other secondary care clinicians – actually sending them into the programme.  So it is a part of the overall pathway and something we’re trying to encourage more people to refer on to.”
  • Create links with and referral pathways to relevant services and partner organisations in the statutory, voluntary and community sectors that also support people to self-manage.  There is an increasing body of evidence demonstrating the benefits of peer support and community groups in combating isolation and helping people sustain their knowledge, confidence and skills to self-manage over time. 
    For example, in Islington, Care Navigators in GP practices ensure that people are linked into support beyond the NHS that can help them to maintain their health. 

It is unlikely that there will be a local directory of all the support that is available, and a first step may be finding what is available and creating a local directory of services that clinicians can use to signpost people to relevant support.

Read more about peer support and community assets

  • Ensure that self-management support is included in other relevant service developments that are taking place.  Integrating the work enables greater impact and increases the potential for self-management support to be sustained and spread.
    For example, in Ayrshire & Arran, work has been carried out with the Telehealth service to link self-management support to the care pathway.

    “What they’re looking at now is trying to deliver that Telehealth and prevention using things that people already have, like apps for Iphones, Ipads and digital TV and things which don’t make the intervention itself so costly....that’s an additional way that we can reach a group of people and become embedded in a pathway that we hope is going to be an established pathway anyway, because the Telehealth programme’s not going to go away.”

    In Guys’ and St Thomas, the team working on supporting people with diabetes to self-manage built strong links with the Diabetes Modernisation Initiative (DMI) which led to a toolkit being developed incorporating tools to be used within practices and community teams.  The Diabetes Modernisation Initiative is now continuing to implement self-management support through its links within the wider health economy.
  •  Incorporate self-management training for patients into other relevant patient programmes.  For example, self-management can be incorporated into core rehabilitation programmes, such as Pulmonary Rehab for people with COPD, and then linked in to relevant services such as the equipment service.
    For example, the team in Cambridge working on the Health Foundation’s Co-creating Health programme reviewed their Pulmonary Rehab programme and have developed an Enhanced programme that has an extra focus on helping participants to develop their skills in setting their own health goals and how these are followed up.  In this way, the enhanced programme combines COPD education with training and support to develop patients’ skills and confidence in self-management.
  •  Promote self-management messages and materials.  These can be provided both within the health service and beyond.  Materials can be displayed in public venues such as libraries and community centres, as well as in areas such as GP waiting rooms.  They can take the form of posters, leaflets, or information on your website.  People with long term conditions can often identify effective methods, approaches and places for sharing information about self-management that may not be obvious to services. 

    See an example poster.