The SmartCare pathways

The SmartCare pathways have been designed around two major service scenarios:

  • Integrated long term care support at home (ICP-LTCare pathway)
  • Integrated care following hospital discharge (ICP Discharge pathway)

Both scenarios respond to a recognised need for improved integration at crucial junctions in health and social care service delivery.
Each pathway consists of three major phases which are again separated into different steps:

  1. Entering into the SmartCare pathway
  2. Receiving continuous personalised (health and social) care
  3. Leaving the SmartCare pathway

SmartCare pathway for long-term care

SmartCare pathway for hospital discharge

Entering into the SmartCare pathway

"You can't integrate all of the services for all of the people all of the time." (Leutz 1999) This fundamental dilemma of integrated care points to the need to clearly identify patients that may benefit most from the integrated delivery of health and social care.

This situation is typical for a SmartCare service configuration in the deployment sites that are implementing the hospital discharge pathway. Jose is a clinically stable patient with support needs at home and with his COPD condition likely to benefit from regular monitoring, possibly through a tele-monitoring application and from receiving social care services such as meals on wheels for a certain time. He also fulfils the age related inclusion criteria and may have problems coping with daily household duties. Before actual service delivery begins, a potential SmartCare service user needs to be referred by either a healthcare or a social care provider. Depending on the characteristics of the health and social care system, direct subscription by a service user themselves or a family member is also possible. When it comes to hospital discharge in particular, the entry point is usually defined by a pending discharge event.

The referral is followed by a needs assessment which targets both health and social care needs. It is a first junction for collaborative work of health and social care service providers and focuses on assessing the individual service user in relation to any home care need they may have. It should enable the identification of health-related needs as well as needs for other forms of home support. Upon completion of the assessment, the service user is enrolled into the services and an integrated care plan is agreed jointly by health and social care providers. The integrated care plan is a formal document that describes the services to be provided to the care recipient and the appropriate intervals. It guides the care team by establishing a course of client care, priorities and selecting a course of action from identified alternatives. It is regularly revised according to the (changing) needs of the service user. The care recipient is consulted on organisational matters such as the preferred day of the week for nurse visits or follow-up phone calls.

The hospital discharge pathway is designed to meet the needs of patients who face dis-charge from hospital and transfer to their home setting. The important difference to the long-term care pathway is the elaboration of an initial integrated care plan prior to discharge from hospital. In both service scenarios, regular monitoring of the service user's health status and needs allows for temporary (re)admissions to hospital or residential care, if needed.

Continuous personalised care

Service users in the SmartCare deployment regions benefit from different service configurations that are augmented by technology and backed up by the cooperation of service providers and the joint documentation of care. This is crucial for the effective coordination of care delivery. The personalised care delivery package at the centre of the SmartCare pathways combines both informal and formal care delivery as well as remote support delivered via telecare and/or telehealth services.

The story of these two users is taken from the Italian deployment region of Trieste. Field visits by the SmartCare User Advisory Board have identified the particularity of this personalised service delivery model. It builds on the traditionally strong role of nurses and a strong collaboration of health and social care professionals. The shared care record is predominantly used by nurses, but is also accessible to other care professionals as well as the service user and informal carers. The clinical adjustment to medication and alert levels is done by a GP in close consultation with the nurses. For patients in remote areas living in isolation, a social care worker is also available. Information from the encounters is also integrated into the shared care record system.

The patient story clearly shows the pathway steps concerned with the care delivery, the joint documentation and the continuous re-assessment of the service user's needs. Joint coordination of integrated care service delivery focuses on the continuous tracking of SmartCare service users when they receive professional home care and/or informal support from different parties as identified in the initial care plan. It enables carers to coordinate delivery of required care interventions and effectively utilise available resources. As a consequence, the right mix of clinical, social and informal care in line with the care plan is delivered. The documentation of any care provided to the service user needs to be available in an integrated manner and serves as a basis for ongoing decision making within the overall care process between all involved caregivers.

Integrated care provision following the SmartCare pathways also includes a regular monitoring and re-assessment of the needs of the service user and adaptation of the care plan accordingly. Should a patient no longer require care in one of the two pathways, a disenrollment is possible.

Joint documentation and coordination of care provided

None of the above interactions are possible without a joint documentation system. The below is an example of the different record systems that usually interact in a SmartCare type scenario, depending on regional context and legacy systems of course:

  • Hospital Health Care Record System: generates the admission, readmission and discharge summaries, the health home care plan; accepts information from the SmartCare system into CR health care record; prepares and documents CR consent for participation in SmartCare System
  • Community Health and Social Care System: generates health and social care plan, documents health social care provided along with review and assessment of care provided, provides health and social care discharge summary for SmartCare service exit and/or admission to the hospital
  • General Practitioners (GP) systems: prepares and documents consent for participation in SmartCare system; receives discharge summary information from Hospital Health Care Record System; generates and/or receives hospital re-admission information for home care recipient; generates and/or receives SmartCare discharge and/or referral (for ICPLTCare) information for home care recipient
  • Caseload management and appointment systems: generates interventions and services for formal health, social and informal care workers for care delivered in home; this may be separate systems providing a similar function by the different SmartCare users
  • Telehealth and telecare systems: measures vital parameters prescribed by home healthcare plan; measures environmental and social parameters prescribed by home social care plan; provides automated alerting of critical situations to health or social authorities; provides virtual access to formal health, social care and informal care providers for home care recipient
  • Care Recipient held record: information care recipient documents regarding the care they receive


Leutz, W. (1999). "Five laws for integrating medical and social services: Lessons from the United States and the United Kingdom." The Milbank Quarterly 77(1): 77-110.