A quality perspective on the ideal of coherent care pathways for patients with complex, long-term healthcare needs. A policy document analysis

Abstract

Background: Policy documents’ rhetoric emphasize coherent care pathways as an expression of integrated and person-centred care in healthcare services for persons with complex long-term needs. Various measures are introduced to achieve these ideals. Norwegian policy highlights personal responsibility for one professional as a coordinator, cross-sectional individual care plans, services provided by multidisciplinary teams, formal collaboration structures between primary and specialized care, and implementation of different types of pathway organization. Policy documents rarely specify how quality in terms of goal achievement is to be understood, assessed, or evaluated. It has proved difficult to show outcomes of the measures as well as whether they contribute to achievement of the ideals. 
 Theoretical framework: Four quality paradigms have been demonstrated as a common basis for assessing quality in integrated care: the empirical paradigm which focus on measuring reality, the reference paradigm where care is evaluated according to models or frameworks, the reflective paradigm where quality cannot be defined, just discussed. And finally, the emergence paradigm where all stakeholders explore and co-create new solutions together.
 Aim: To analyse how ideals of coherent care pathways are described in policy documents, and how they resonate with different quality paradigms. 
 Methods: An analysis of two central Norwegian policy documents is in process. The meaning of ‘care pathway’ is interpreted in the context of each paragraph, and categorized according to which quality paradigm(s) is considered relevant. 
 Preliminary results and discussion: The concept ‘coherent care pathways’ is used as an expression of, and as an argument for, a variety of models, care organization, care values, and desirable patient experiences related to process-oriented care. Achievement of coherent care pathways for persons with long-term complex healthcare needs, can therefore imply different types of “success”. 
 One type of model is standardized clinical pathways. Here quality is defined as timely accomplishments of defined tasks. This is in accordance with the empirical paradigm. In the Norwegian coordination reform, care pathways is defined as the chronological chain of events that make up the patient's encounters with various parts of the health and care services. In good pathways these events are put together in a rational and coordinated way to meet the patient's various needs. Pathway in this meaning must be evaluated in perspective of the individual patient’s situation, considering the degree of predictability and the prerequisites for planning during the process. This in accordance with the emergence paradigm.
 Van Kemenade, van der Vlegel et al. (2019, 2020, 2021, 2022) have introduced the quality paradigms in analysis of, and recommendations for, integrated care research, to show different understandings and values at play in a patient case, and to propose a new definition of integrated care. In this paper we intend to discuss how conceptualizations of coherent care pathways in policy documents has consequences for how quality can be understood and evaluated. And further, that we can draw relevant knowledge from this of benefit to discussions and plans for realizing the measures and the ideals of integrated person-centred care. 
 Keywords: Care pathways, integrated care, person-centred care, quality paradigms.