The development of a care pathway across the primary – hospital care continuum, supported by a step-by-step scenario, led to the enhancement of inter-organizational mechanisms and network components of the multi-level framework. Local community projects evaluating an existing care pathway already had taken initiatives to enhance these components during the development of the first version of the care pathway. Regional differences had an influence on the use of (new) structures, networks, the creation of a sense of “ownership” and data gathering. No differences were found between the two diagnostic groups.
The process of developing a care pathway led to the use of existing and newly developed structures. The construction of a good structure, taking into account existing structures and communication channels was considered even more important than the development of the care pathway per se: key contacts were made, healthcare professionals got to know each other and partnerships were built. Currently hospital care in Belgium is more structured than primary care. Nevertheless it is widely accepted that a strong primary care system can improve the coordination and responsiveness in health care . Healthcare systems recognizing the importance of primary care to coordinate care, who are regionally organized (including hospital care) and have their own resources to respond to their experienced need, will have more structural support available for developing and implementing care pathways between primary and hospital care. Without these necessary preconditions, it will be up to “early innovators” to change things in the existing systems and frameworks.
General practitioners are often considered to be the structural link for coordinating between primary and hospital care for the individual patient. However, the electronic health records that are needed for the exchange of relevant information and for providing the necessary links are often lacking .
The support of and integration into IT applications was considered to be another essential element for the future of care pathways. A systematic review of the impact of eHealth on the quality and safety of healthcare concluded that there is a large gap between the postulated and the empirically demonstrated benefits of eHealth technologies . Another systematic review, studying the effects of health information technology, found in 62% of the studies that one or more aspects of the care improved with no aspects being aggravated, 30% of the studies had mixed results, and 8% did not produce any positive results. An analysis of these negative studies teaches us that the human factor is very important, more specifically the satisfaction people gain by using these electronic systems .
All the local community projects have experienced problems with the implementation of the developed booklet or leaflet in daily practice. In a case study about the development of a patient safety care pathway, separate tools were developed to represent the care pathway, to coordinate healthcare professionals’ activities and to account for action to meet the multiple purposes and the multiple stakeholders of the care pathway . Developing different documents could resolve the current difficulties being experienced with implementation.
The local community projects started with the existing 30-step care pathway methodology  to develop, implement and evaluate a care pathway across the primary –hospital care continuum. The importance of including all relevant stakeholders and the benefit of continuous and reflective learning was also demonstrated in a study about the development of a care pathway across different settings and independent disciplines . Reviewing both the evidence of and the feedback on the actual organization of the care process are two important aspects in the methodology of care pathways [9, 15]. Nevertheless, little evidence exists for the purpose of formulating key interventions and outcome indicators across the primary – hospital care continuum [32–36]. A certain amount of variation is accepted, so that pathways can be tailored for particular purposes and creative solutions can be developed for managing the interdependencies of their components in particular circumstances . Some variations were found related to the specific characteristics of the primary – hospital care continuum.
The experiences of these local community projects have contributed to the revision of the existing step-by-step plan into a model of seven phases . Moreover, these results were translated into a blueprint for projects aimed at developing a care pathway either in primary care alone, or in primary care together with hospital care.
The inter-organizational mechanisms had an effect on the relationships between the healthcare professionals involved. Timely and accurate communication and information exchange between the primary and the secondary healthcare professionals involved is often inadequate or even lacking . Poor communication between agencies and a lack of understanding of each other’s roles and responsibilities are barriers to coordinating multi-agency practice . Staiger  formulates the future challenges in terms of redefining the roles and supporting the staff in their efforts to develop effective strategies to enhance communication, collaboration and coordination between the acute and the community health sectors. The local community projects used a variety of strategies to involve all healthcare professionals. Grol  emphasizes the importance of using a multifaceted approach via existing channels and structures to implement Evidence-Based Guidelines for clinical practice.
The five selected local community projects developed, implemented and evaluated a care pathway for patients with surgery after a diagnosis of breast or prostate cancer. The conclusions formulated were not tested for other pathologies. Since our focus was on the process of developing, implementing and evaluating care pathways, the conclusions formulated are likely applicable to other pathologies.
The care pathways developed in the five local community projects were guided by a 30-step scenario and had partial support (academic and financial). These additional supports have a beneficial influence on the findings of this study.
Many strategies were used to ensure validity and reliability . Multiple data sources were used in the five local community projects, so that the results could be confirmed both within and between cases. The multi-level framework guided the analysis. The results were substantiated with empirical evidence and discussed with other researchers and members of the local community projects.
The development of a care pathway across the primary-hospital care continuum, supported by a step-by-step scenario, led to the enhancement of inter-organizational mechanisms and network components of the multi-level framework. To support the development of care pathways, policy makers need to provide the necessary structure so qualitative relationships can be built. The integration of care pathways into current IT applications is essential, taking into account the needs and expectations of healthcare professionals. More research is required to study the effects of care pathways across organizational boundaries on the coordination and quality of care.