The document discusses care pathway planning and outlines key components of a care pathway plan, including a formulation/needs assessment, pathway map, health outcomes and goals, activity/therapy plan, and support plans. It provides learning points around defining the destination and route in a patient's pathway, ensuring health outcomes map over the entire pathway rather than being service-specific, distinguishing between pathway-critical and non-critical health outcomes, and linking interventions to outcomes. The document emphasizes that care pathway plans should be personalized for each patient.

1. Care Pathway Planning
Comprehensively simple
Keith Barry, Group Head of Nursing
Leigh Allen, PathNav Clinical lead

2. Introduction and
Overview

3. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
3

4. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
Construct of a Care Pathway Plan
The plan (or Care Plan) might include:
1. Context for how you arrived at the start of the journey, what’s going to
help you along the way, and what’s going to impede your progress. Who
are you traveling with, and what do they bring? (Formulation/Needs
Assessment)
2. Clarity about the end destination & the route you’re taking (Pathway
map)
3. Knowing what you need to do to get from point to point in the journey
(Health outcomes/goals)
4. A training plan. What skills and abilities am I going to need to accomplish
the journey? (Activity/Therapies)
5. What’s the plan if I get ill or need help along the way? (Support plans)

5. 5
Formulation Pathway plan Health outcomes Special
arrangements
Describes the risks,
contributing factors, skills and
vulnerabilities of the patient
which informs health needs
and goals.
A simple plan that
illustrates/describes the
expected/proposed pathway
through services a patient will
take to the community or to
the most realistic final service
destination.
I.e Medium Secure, In-patient
Rehabilitation, Supported
Living.
A detailed plan defining overarching
outcome areas (or domains) and
specific outcome items that will help
achieve that outcome area. It will
detail the interventions necessary to
achieve those health outcomes. This
plan is likely to be a medium to long
term plan reviewed at care review
meetings. Every patient should have
a copy of their outcomes plan and
know which outcomes are critical to
achieving the pathway plan.
I.e. Outcome – Developing Insight.
Outcome item - Insight into my
mental disorder,. Intervention –
Mental Health Awareness
programme.
An individual plan developed and
managed at ward level that
describes the routine management
of a persons care or the control of
immediate risks. One plan may
address multiple items of concern.
Likely to be reviewed routinely at
ward level in nursing or MDT
meetings and may feature in Care
Review meetings.
I.e. Advance directive, how obs are
managed, management of self
harm, management of violence,
specific security considerations,
specific family, contact, visiting
considerations etc.
Sources:
PathNavPathNav PathNav Clinical record
RIO/Carenotes
etc
Activity
timetabling

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Uncompromising integrity • Valuing people
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2. Destination & route
Learning:
•Testing with clinical teams shows that for most patients it is possible to make
a reasonable judgement about the final and most realistic point in a patient’s
journey.

7. 7

8. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
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2. Destination & route
Learning:
•Testing with clinical teams shows that for most patients it is possible to make
a reasonable judgement about the final and most realistic point in a patient’s
journey.
•When you have mature, multi-disciplinary and ‘evolved’ clinical teams it’s not
at all difficult. Where the problems arise is when teams are suffocated by
feeling they need to use all parts of the pathway.
•Most often, patients value seeing the full picture of their journey and the
services they’ll use. It often repositions their ideas of the next point in the
pathway.
•It does demand though, that we’re more open about those patients who are
likely to reach the limit of their integration with the community in inpatient
services. We’ve referred to this as enduring care.

9. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
3. Health outcomes
Patient experience
measures
Life goals/aspirations
and hopes
Interventions
Factors a person feels are important
to their care or to the experience
they have while in care. Patient-
defined experience measures do not
always fit perfectly with health
outcomes but should always be
listened to and where possible taken
into account.
Important goals people want to
accomplish in life or ideals they
wish to uphold. These should be
properly understood by a clinical
team and supported where it is
reasonable to do so.
Treatment and therapy packages
that might (or might not) support
health outcomes i.e. CBT.
Completion of intervention does
not necessarily mean a health
outcome has been achieved.
Risk management
arrangements
Special Arrangements to prevent,
minimise or manage understood
risks. i.e. 1-1 observation, access
to high risk items or observation
of visits etc.
Personal support
arrangements
Special Arrangements to support
personal care, physical health or
other cultural/personal needs etc.
i.e. personal care plan, detailed
chronic condition plan etc.
Health outcomes
The specific health result a patient
and clinical team need to achieve
(or contribute to) together to
enable the treatment pathway to
be completed. They need to be
specific, measurable and fair.

10. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
3. Health outcomes
Patient experience
measures
Life goals/aspirations
and hopes
Interventions
Factors a person feels are important
to their care or to the experience
they have while in care. Patient-
defined experience measures do not
always fit perfectly with health
outcomes but should always be
listened to and where possible taken
into account.
Important goals people want to
accomplish in life or ideals they
wish to uphold. These should be
properly understood by a clinical
team and supported where it is
reasonable to do so.
Treatment and therapy packages
that might (or might not) support
health outcomes i.e. CBT.
Completion of intervention does
not necessarily mean a health
outcome has been achieved.
Risk management
arrangements
Special Arrangements to prevent,
minimise or manage understood
risks. i.e. 1-1 observation, access
to high risk items or observation
of visits etc.
Personal support
arrangements
Special Arrangements to support
personal care, physical health or
other cultural/personal needs etc.
i.e. personal care plan, detailed
chronic condition plan etc.
Health outcomes
The specific health result a patient
and clinical team need to achieve
(or contribute to) together to
enable the treatment pathway to
be completed. They need to be
specific, measurable and fair.
Health outcomes
The specific health result a patient and clinical team
need to achieve (or contribute to) together to enable
the treatment pathway to be completed. They need to
be specific, measurable and fair.

11. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
3. Health outcomes
Learning:
•Health outcomes map over the entire pathway. There aren’t outcomes for
medium secure and outcomes for low secure. There are outcomes for people.
•Defining the progress points (or steps) within an outcome in relation to the
pathway is really important. Grading 1-5 just isn't good enough.

12. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
3. Health outcomes map over the pathway

13. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
3. Health outcomes
Learning:
•Health outcomes map over the entire pathway. There aren’t outcomes for
medium secure and outcomes for low secure. There are outcomes for people.
•Defining the progress points (or steps) within an outcome in relation to the
pathway is really important. Grading 1-5 just isn't good enough.
•Distinguishing which health outcomes are ‘Pathway critical’ and which you
can take with you are really important.

14. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people

15. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
3. Health outcomes
Learning:
•Health outcomes map over the entire pathway. There aren’t outcomes for
medium secure and outcomes for low secure. There are outcomes for
patients.
•Defining the progress points (or steps) within an outcome in relation to the
pathway is really important. Grading 1-5 just isn't good enough.
•Distinguishing which health outcomes are ‘Pathway critical’ and which you
can take with you are really important.
•‘Static’ outcome tools miss an opportunity to be helpful. Being able to ‘bin’
outcomes that aren't relevant and being able to write patient specific
outcomes is critical to any outcome tool being safe, clinically sensitive and
personalised.

16. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people

17. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
3. Health outcomes
Learning:
•Health outcomes map over the entire pathway. There aren’t outcomes for
medium secure and outcomes for low secure. There are outcomes for people.
•Defining the progress points (or steps) within an outcome in relation to the
pathway is really important. Grading 1-5 just isn't good enough.
•Distinguishing which health outcomes are ‘Pathway critical’ and which you
can take with you are really important.
•Static outcome tools miss an opportunity to be helpful. Being able to ‘bin’
outcomes that aren't relevant and being able to write patient specific
outcomes is critical to any outcome tool being safe, clinically sensitive and
personalised.
•Making a clear link between interventions and outcomes is important.

18. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people

19. Taking quality to the highest level • Working together • Caring safely •
Uncompromising integrity • Valuing people
19
Summary
• Having a clear pathway is critical, but it’s only part of a much more
comprehensive approach
• Clearly stated heath outcomes are essential to transitions - knowing what
to reach for and knowing when it’s ok to move on
• Care plans, recovery plans, CPA plans – call them what you like but
patients most probably only need one ‘comprehensively simple’ plan
• Successful pathways also need to be clinically efficient. Building a process
that takes more clinical time to administrate prolongs journeys rather than
shortens them.

20. Keith.barry@partnershipsincare.co.uk
Leigh.allen@partnershipsincare.co.uk
Thank You