Design a chronic disease care pathway that sequences diagnosis, treatment initiation and ongoing review.
Healthcare & Pharmaceutical Management
Chronic Disease Care Pathway Design and Management
Trains service designers to build chronic disease care pathways spanning diagnosis, self-management support and long-term monitoring, and to manage the pathway once it is live.
🗓️Duration5 training days
📚Content4 modules · 8 sessions
🎓On completionAccredited attendance certificate
About the programme
Course Overview
A chronic disease care pathway is the sequence of contacts, decisions and handovers a patient experiences from diagnosis onward, and when that sequence is left to happen by default rather than by design, patients fall through gaps between specialists, primary care and self-management support. This course builds the skills to design that pathway deliberately and to keep managing it once it is running. Participants start from diagnosis and risk stratification, work through the self-management education and behaviour change techniques that reduce dependence on reactive care, and design the monitoring and review schedule that catches deterioration before it becomes an admission. A dedicated module covers pathway variance analysis: how to compare what actually happens to patients against the designed pathway, and use that gap to prioritise redesign. The course closes with the governance side of pathway management, including how a pathway is updated as evidence and guidelines change without losing consistency for patients already partway through it.
Expected Learning Outcomes
Stratify a chronic disease population by risk to target monitoring and support proportionately.
Select self-management education and behaviour change techniques suited to a specific condition.
Design a monitoring and review schedule that detects deterioration before it triggers an admission.
Conduct a pathway variance analysis comparing actual patient experience against the designed pathway.
Coordinate a chronic disease pathway across primary care, specialists and community services.
Update a live care pathway to reflect new guidance without disrupting patients already on it.
Who Should Attend
Long-term condition service leads designing or redesigning a care pathway.
Primary care clinicians managing chronic disease registers and reviews.
Specialist nurses delivering self-management education and monitoring.
Commissioners and planners overseeing integrated chronic disease programmes.
Quality improvement leads conducting pathway variance and audit work.
Community health workers supporting patients between clinical reviews.
Course Modules
Select any module to see its sessions and points.
01Diagnosis, Risk Stratification and Pathway Entry
2 sessions · 8 points
Session 1Structuring the Pathway from Diagnosis Onward
- Sequence the pathway steps from initial diagnosis through treatment initiation and first review.
- Define entry criteria and confirmatory tests required before a patient is placed on the pathway.
- Set the information and consent conversation a patient receives when a chronic condition is diagnosed.
- Identify handover points where responsibility moves between primary care and specialist services.
Session 2Risk Stratification and Tiered Support
- Stratify patients into risk tiers using clinical markers, prior admissions and self-management capability.
- Assign a review frequency and support intensity to each risk tier within the pathway.
- Re-stratify patients periodically so support intensity reflects their current rather than initial risk.
- Identify patients whose risk tier should trigger case management rather than routine pathway review.
02Self-Management Support and Behaviour Change
2 sessions · 8 points
Session 1Designing Self-Management Education
- Select self-management education content and format appropriate to the condition and patient literacy.
- Build a structured education programme covering symptom recognition, medication and lifestyle factors.
- Use teach-back techniques to confirm patient understanding rather than assuming comprehension.
- Adapt self-management education for patients with additional language or cognitive support needs.
Session 2Applying Behaviour Change Techniques
- Apply goal-setting and action-planning techniques to support sustained behaviour change.
- Use motivational interviewing approaches to address ambivalence about treatment or lifestyle change.
- Design peer support or group-based components that reinforce individual self-management goals.
- Track self-management engagement indicators to identify patients disengaging from the pathway.
03Monitoring, Review and Escalation
2 sessions · 8 points
Session 1Designing the Monitoring and Review Schedule
- Set monitoring parameters and review intervals appropriate to the condition's typical rate of change.
- Combine remote monitoring data with scheduled clinical review to reduce unnecessary face-to-face visits.
- Define escalation thresholds that move a patient from routine review to urgent clinical assessment.
- Coordinate monitoring data flow between the patient, primary care and specialist teams.
Session 2Coordinating the Pathway Across Providers
- Agree shared protocols between primary care and specialists for medication titration and referral.
- Design a single shared care record that all providers on the pathway can access and update.
- Resolve conflicting guidance between providers before it reaches the patient as inconsistent advice.
- Set a joint review point where primary care and specialist teams reconcile a patient's overall plan.
04Pathway Variance Analysis and Governance
2 sessions · 8 points
Session 1Analysing Variance Between Design and Delivery
- Compare actual patient contact patterns against the designed pathway to identify systematic variance.
- Distinguish acceptable clinical variation from variance caused by capacity or coordination failure.
- Prioritise pathway redesign effort on the variance points affecting the most patients or the highest risk.
- Present variance findings to the multidisciplinary team responsible for the pathway.
Session 2Governing and Updating the Pathway
- Establish a governance process for approving and version-controlling pathway changes.
- Update pathway protocols when clinical guidance changes without disrupting patients mid-pathway.
- Communicate pathway updates consistently to every provider and team involved in delivery.
- Review overall pathway outcomes annually against the goals set when the pathway was designed.
What the participant receives
4 course modules
A structured syllabus
8 training sessions
across 5 days
32 detailed points
Applied, detailed content
Accredited attendance certificate
On completing the programme
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