A healthcare network that works on paper but where no one knows who coordinates what: this is the reality of many care pathways in France. The problem is not the absence of structures, but their clarity for the patient and for primary care professionals.
Invisible coordination: when the healthcare network exists without being reachable
A CPTS registered in a territory does not guarantee that its services are accessible to all patients in the area. The gap between the administrative existence of a system and its actual availability constitutes the first point of friction in the pathway.
In Haut-Bocage, a feedback report published in September 2026 describes a non-scheduled care center, a waiting list to obtain a primary care physician, and a health desk. However, the phone wait time at 116-117 is cited as a persistent barrier. The system exists, but the patient struggles with the access channel even before entering the pathway.
This is not an isolated case. The articulation between CPTS and multi-professional health houses can become a significant operational issue. When two structures overlap without a clear protocol for distribution, the primary care physician themselves sometimes does not know to whom to address a request for support. A high-performing healthcare network is distinguished by a simple criterion: the ability to identify in less than a few minutes who does what for a given patient.
Healthcare professionals document these coordination efforts, and platforms like le-reseau-sante.fr structure information to make the actors in a territory identifiable to patients and caregivers.
Territorial support functions: what primary care teams cannot do alone
The HAS defines support functions as all activities necessary for organizing pathways but that cannot be directly performed by primary care professionals. Three situations justify this recourse:
- The active patient list of a practice is too small to pool certain resources at the level of its own patient base, necessitating organization at the territorial level
- The patient needs technical, social, or support skills that the general practitioner does not master (therapeutic education, help navigating the system)
- Professionals do not have, in their current organization, the means to provide these services (coordination secretariat, post-hospitalization follow-up)
Territorial support is not an organizational luxury, it is a condition for the functioning of the pathway for patients with chronic illness. We observe that these functions remain underutilized when they are not associated with a transfer of know-how to primary care teams. The goal is not to create an additional administrative layer, but to ultimately enable primary health teams to perform all or part of these services themselves.
Occasional support for follow-up (multidimensional assessment, personalized health plan) differs from assistance throughout the pathway. Confusing the two amounts to mobilizing heavy resources for light needs, or leaving complex situations without support.
Differentiating occasional help and pathway assistance
The initial assessment of a patient, conducted only once to guide care, falls under occasional help. It can be triggered by the primary care physician without initiating continuous follow-up.
Pathway assistance involves an identified contact over time, capable of reacting when a disruption occurs: unplanned hospitalization, loss of the primary care physician, change in social situation. This function is lacking in the majority of fragmented pathways.
My health space and data control: an underutilized coordination lever
Digital coordination among professionals depends on concrete rules for sharing and controlling data by the patient. My health space allows the user to authorize or block access for professionals, hide documents, and manage access in emergency situations.
These parameters are not trivial. A document hidden by the patient can create a clinical blind spot for the next professional in the care chain. Conversely, overly broad access exposes sensitive information without direct therapeutic benefit.
The configuration of My health space thus becomes a full-fledged coordination act. A high-performing healthcare network integrates this issue into its protocols: who informs the patient of their sharing options, at what point in the pathway, and how the professional verifies that they have the necessary documents before a consultation.
Interoperability of health documents
The exchange of data between professionals relies on interoperability standards (FHIR framework, ANS documentation component). Without these standards, each business software produces documents in its own format, unreadable by the neighboring system. Technical interoperability conditions the informational continuity of the pathway.
A network may have the best clinical protocols: if the hospitalization report does not arrive in the primary care physician’s software before the follow-up consultation, coordination remains theoretical.
Relevance of care and patient pathways: going beyond the logic of isolated acts
The ARS has a regulatory mission to support the improvement of pathway relevance. The regional body for improving care relevance (IRAPS), defined by decree n° 2015-1510 of November 19, 2015, meets twice a year and contributes to the development of the regional multi-year action plan (PAPRAPS).
Relevance is not limited to the question “was this act necessary?”. It concerns the coordination of multiple actors around the health pathway, including the patient and their entourage, health and social systems. A relevant act performed at the wrong time in the pathway, or without transmitting information to subsequent interveners, loses part of its value.
The regional action plan gains effectiveness when it is based on field data reported by primary care professionals. This is the hardest loop to close: feeding back observed pathway disruptions in practices to territorial steering bodies, then translating these observations into operational protocols.
Improving a care pathway cannot be decreed from a regional body. The quality of the pathway is determined at each transition between two professionals, at each phone call that succeeds or fails, at each document shared or withheld. The high-performing network is one where the patient knows who to call, and where the professional knows who saw the patient before them.
