Table 1.

Care pathway elements and supportive measures.

No.	Name	Description
	Care Pathway Components
1	Registration	To assure timely and equal access for all eligible patients, registration has to be low-threshold with easy-to understand clinical registration criteria and registration rights to all community-based neurologists, GPs and patients themselves.
2	Pre-consultation patient self-monitoring	Prior to a consultation at one of the specialized centers (“Parkinson center”), patients will receive standardized self-monitoring packages to ensure availability of relevant patient information.
3	Triage	Based on the pre-consultation self-monitoring, patients will be triaged according to the criteria of urgency and expected therapeutic complexity.
4	Specialist consultation	Tasks and responsibilities will be clearly defined and assigned among center staff to allow physicians to focus on the medical core aspects.
5	Individualized ongoing intersectoral care plan	Following a consultation, specialists are to plan the relative contribution of the Parkinson center and the treating community-based physician on an individual patient-to-patient basis.
6	Repetitive patient self-monitoring	All patients will receive self-assessment monitoring packages at quarterly intervals to allow for timely detection of changes in condition.
7	Consultation with community-based physician	As planned by the individualized ongoing intersectoral care plan, patients are seen by their community-based physician whose responsibilities are defined by the care pathway. If indicated, the physician can prompt changes in the treatment plan, e.g., by asking for an intensified contribution of the Parkinson center.
	Supportive personal, technical and communicative measures
1	Electronic health record (EHR)	All patient-related information will be recorded in a collaborative electronic patient management/documentation platform that all involved healthcare providers have access to.
2	Intersectoral specialized case management	A team of case managers who specialize in PD care will be the personal backbone of the Parkinson Network Eastern Saxony (PANOS). They will serve as an individual patient’s care coordinator and as the first contact person to the patient and all involved healthcare providers. In PANOS, they will be additionally responsible for network management activities, carrying out the structured patient school and support physicians in Parkinson centers and private practices.
3	Active network management	Ongoing mobilizing initiatives to promote the motivation of community-based physicians to become an active collaborator.
4	Structured patient school according to self-management concept	Modular group-based patient education program to promote self-management competences.
5	Electronic patient letter	A patient-orientated version of medical documents, automatically generated based on the information available in the EHR.
6	Structured professional continuous education curriculum	An education curriculum will be developed addressing the specific education needs of both neurologists and GPs.
7	Ongoing quality management	Ongoing quality management to assure adherence to process standards and an equal quality of care provided across the entire PANOS network.