Service processes based on pathways

While the pathways represent a generic view of an integrated eCare service, the service process models visualise how the workflow of the generic model is implemented in a particular regional implementation context.

In that sense, the service process model presents a schematic and structured overview of the sequence of actions that are taken by the different regional actors involved in service delivery to an individual service recipient, i.e. a patient or client. Formally, a standard set of elements is used. The elements are linked by arrows which can be looped to lead back to a process further up in the flow chart. Decisions are usually binary, and marked with (yes/no). If processes involve several stakeholders, they are stretched across generic roles (e.g. healthcare provider, social care provider, third sector care provider and informal / family care provider).

Two service process models were developed for each deployment region, one visualising the contextualised workflow of the SmartCare pathway for integrated home support to people with long term care needs (ICP-LTCare), and the other visualising the contextualised workflow of the generic pathway for integrated home support after hospital discharge (ICP-Discharge). Both service models include transfer points into each other, and can in principle be viewed as a single one, whereby entry points into the overall SmartCare service vary across individual users.

The figure below is an example of such a service process model, taken from the Scottish deployment region. The numbers in hexagonal boxes refer to elements of the pathway, as further described below.

The table below provides an explanation of the actor acronyms used in the figure:

AcronymType of actorExplanation
SU Service User Person in receipt of a service
I/FC Informal / family carer Friend or Family member support
SCP I Social Worker Officer from Local Government Social Services or Independent Sector
SCP II Home Care Worker Carer employed by statutory agency or independent sector
JT I Hospital Discharge Multidisciplinary Team including Social Worker
JT II Falls Team Multidisciplinary Team AHP's dietician, rehab nurse, including social work. Carer employed by statutory agency or independent sector
HCP I GP General Practitioner at Local Level
HCP II Community Nurse Nurse who provides a service to people at home
HCP II1 Primary Care Range of Health Care professionals
TSCP I Go for it Digital Inclusion Coaches
TSCP II Invigor8 Exercise Classes
TSCP III Third Sector interface Social Activities


Numbers in hexagonal boxes refer to the following elements of the SmartCare pathway:


Assessment of the service user's need for integrated care


Enrolment into the SmartCare service


Initial integrated home care plan


Coordination of integrated care delivery / revision of the initial care plan


On-site provision of medical, social and informal care


Remote provision of integrated care to the home


Integrated documentation of home care provided / self-care measures


Control / reassessment of the home care recipient


Temporary admission / re-admission to an institutional setting (e.g. hospital, day care centre)