FACT SHEET – Evaluating territorial coordination in support services – Methodological clarifications

This fact sheet is directly useful to management, executives, quality professionals, and evaluators of ESSMS engaged in service transformation (integrated systems, platforms, multi-ESSMS). It allows for reading the HAS reference framework "ESSMS" through the lens of territorialised, modular, and coordinated pathways. It provides concrete benchmarks for organising evaluations (accompanied markers, targeted markers, system audit) and objectifying the quality of territorial coordination.

Source: High Authority of Health (HAS), DIQASM project team (Marion Tallet, Clarence Firpion, Hélène Lussier)

📜🔗LINK

Number of pages: 12

1. Analytical summary

1.1. Context, issues, and target audiences

The document is part of the transformation of the medico-social, social and health offer, which shifts from a logic of places to a logic of personalised, adaptable and evolving pathways, centred on self-determination, access to common law and continuity of responses. Historically driven by the field of disability (2005 law, 'Accompanied Response for All', SERAFIN-PH, 2023 circular on the 50,000 solutions), this transformation is now expected for all ESSMS, including the children's sector. It particularly concerns the systems structured as DITEP, DIME, PCPE, territorialised platforms, organisations combining accommodation and mobile teams, or multi-ESSMS configurations of the same manager. The document targets evaluating bodies, management, supervisors and field teams, in order to clarify what is meant by 'transformation of the offer' and its implications for the evaluation of territorial coordination of pathways. It serves as a cross-sectional reading tool of the evaluation manual, focused on the ability of ESSMS to personalise, coordinate and secure pathways at the territorial level.

1.2. Operational contributions for evaluation and management

Operationally, the document provides guidelines for planning and conducting an evaluation in the contexts of integrated systems, platforms, and multi-ESSMS projects, by articulating supported tracers, targeted tracers, and system audits. It identifies a core set of criteria from the framework particularly related to the transformation of the offer (1.6.3, 1.17.1 to 1.17.3, 1.8.3, 2.3.2, 2.10.1, 3.4.1 to 3.4.4, 3.8.3) and specifies, for each, the type of questions to ask regarding coordination, partnerships, inclusion, and the flow of information. The document provides concrete examples of selecting supported tracers (DITEP, accommodation system + mobile team) to make visible the modularity of responses and the continuity of pathways. It proposes a transversal questioning grid (information, gathering expectations, taking choices into account) supplemented by reinforced questioning on the continuous adjustment of the offer and the mobilization of territorial resources. Finally, it illustrates, via criterion 1.17.2, how to adapt the evaluative reading to a system (here a DITEP) to assess not only the reaction to disruptions but also the anticipatory and partnership capacity of the system as a whole.

2. Key points of the document 

1. The transformation of the offer: moving to a logic of modular, personalised, and coordinated pathways, based on self-determination, access to common law, and inclusion, within an evolving legislative and strategic framework (laws 2002 and 2005, decrees 2016–2017, circular 2023) (p. 1‑2).

2. Identification of the relevant ESSMS: integrated systems (DITEP, DIME, PCPE), platforms, organisations combining systems (mobile team + accommodation, MECS–IME articulations, groupings) characterised by modularity, the ongoing adaptation of support, and inter-actor cooperation (p. 2‑3).

3. Two major axes of analysis: personalising support and empowering the individual (adapting to choices, diverse modalities, supporting self-determination) and organising territorial coordination to secure pathways (cooperation, continuity, prevention of breaks) (p. 3-4).

4. Planning evaluations in a context of transformation: specific requirements for supported tracers, targeted tracers, and system audits, particularly in the case of multi-ESSMS evaluations by the same manager, to cover all modalities of support and assess transversal management (p. 4-6).

5. Criteria grid of the manual directly linked to the transformation of the offer (1.6.3, 1.17.1-1.17.3, 1.8.3, 2.3.2, 2.10.1, 3.4.1-3.4.4, 3.8.3) and proposals for questioning to make it a dynamic and systemic analysis of pathways, illustrated by the detailed zoom on criterion 1.17.2 in DITEP (p. 7-11).

3. Action points for local actors 

1. Formalise a territorial mapping of resources (healthcare, social, medico-social, common law) and link it to personalised projects, in order to document, at the level of criteria 2.3.2 and 3.4.2, how professionals support access to common law and enrich the support offer (p. 7-8).

2. Structure a system for identifying and managing the risks of breaks (indicators, shared vigilance, procedures) to meet the expectations of criteria 1.17.1 to 1.17.3, particularly in DITEP, accommodation systems + mobile teams and territorialised platforms (p. 3-4 and 10-11).

3. Review the organisation of support methods (presence outside the walls, services in ordinary settings, school and social inclusion, home-based methods) to make the modularity of pathways visible in the tracked individuals and to inform the analysis of criterion 3.4.1 (inclusive approach) (p. 2-4).

4. Develop tools for the circulation of information and coordination (joint meetings, transmission tools, pathway referent, inter-ESSMS protocols) to demonstrate, during the system audit, the coherence of governance and the fluidity of partnerships, in relation to criteria 2.10.1, 3.4.3 and 3.4.4 (p. 5-6 and 8).

5. Adapt the HR policy and the training plan to support the evolution of professional postures towards inclusion, self-determination, and support in ordinary settings, in accordance with criterion 3.8.3 (p. 8).

4. Additional references

🔍➕ For more information, see the articles referenced by "Pratiques en Santé" on the ESSMS ➡️🔗https://pratiquesensante.odoo.com/medico-social-social-essms

5. Cross-sectional analysis — Values of Pratiques en Santé

• Literacy: The document remains technical, intended for professionals familiar with the framework, without simplification tools for audiences with low health literacy, but it clarifies the criteria and provides examples of questioning.

• Empowerment: Self-determination, participation, and respect for the individual's choices are presented as central objectives of the transformation of the offer and criteria 1.6.3, 1.17.1, and 1.8.3.

• Participation: The participation of individuals is mainly understood through their involvement in the personalised project and the collection of their experiences (tracked individuals), rather than through formalised co-construction mechanisms.

• Community health: The collective dimension appears through the integration of local resources, partnerships with the ordinary environment, and joint territorial projects (criteria 3.4.1 to 3.4.3).

• Ethics: The issues of non-disruption, equity of access to common law, and respect for choices are addressed, but without an explicit ethical chapter; they are integrated throughout the criteria and examples.

• Human rights: The document is situated in the continuation of the 2002 and 2005 laws on user rights and equal opportunities, with an emphasis on access to common law and citizenship.

• Intersectorality: It values cooperation between the health, social, medico-social, national education, child welfare, disability support, funders, associations, etc., to secure pathways (criteria 1.17.2, 3.4.2, 3.4.3).

• Partnership: Collaboration models are mainly described through examples (DITEP, mobile team + accommodation, multi-ESSMS), highlighting common governance and shared procedures.

• Combating discrimination: The document does not explicitly address discrimination or minorities, but advocates for an inclusive approach and recourse to common law that helps to limit structural exclusions.

6. Evaluation of the reliability of the resource

• Scientific relevance: The document is based on a solid legislative and strategic corpus (2002 and 2005 laws, 2016–2017 decrees, 2023 circular), a documentary watch, and hearings from federations, ATC and ESSMS, with review by several identified field actors. It is produced by the HAS, a nationally recognised authority in quality matters, and is part of the official evaluation system for ESSMS updated in 2025–2026.

• Operational relevance: The document is highly operational for management, executives, quality professionals, coordinators, and evaluation bodies, as it translates the transformation of the service into observable criteria, examples of tracer selection, and questioning grids that can be directly used to prepare the evaluation and manage the quality of territorial pathways.

7. MCQ — 5 questions

Part 1 — Questions (without answers)

Question 1 (pp. 1‑3)

In the document, how is the "transformation of the medico-social offer" defined?

a) As the creation of new places in institutions

b) As the evolution towards personalised, modular, and coordinated pathways

c) As the merger of all ESSMS in a territory

d) As the obligation to limit oneself to common law

Question 2 (pp. 4‑6)

In a multi-ESSMS evaluation, what is a central issue for the selection of tracer beneficiaries?

a) To choose only individuals housed in residential care

b) To choose individuals followed in only one type of support

c) To cover all types of support offered by the system

d) To exclude complex situations or those at risk of breakdown

Question 3 (pp. 7‑8)

What does criterion 2.10.1 of the manual mainly correspond to in this document?

a) The evaluation of the continuing education of professionals

b) The smooth and secure flow of information between professionals and partners

c) The satisfaction of families regarding accommodation

d) Compliance of the premises with accessibility standards

Question 4 (pp. 10-11)

In the DITEP example, which aspect is particularly highlighted for criterion 1.17.2?

a) The budgetary and financial monitoring of the system

b) The ability to anticipate disruptions and mobilise appropriate partnerships

c) The number of available boarding places in the ESSMS

d) The compliance of menus with nutritional regulations

Question 5 (pp. 3-4 and 8)

Which criterion in the manual is explicitly linked to the adaptation of professional skills to changes in the sector?

a) 1.17.3

b) 2.3.2

c) 3.4.4

d) 3.8.3

Part 2 — Commented correction

Question 1

In the document, how is the "transformation of the medico-social offer" defined?

✅ Correct answer: b) As the evolution towards personalised, modular and coordinated pathways.

📝 Explanation: The document defines the transformation of the offer as the shift to organisations focused on personalised, modular, coordinated pathways, enhancing self-determination, access to common rights, and continuity of responses (pp. 1-2).

Question 2

In a multi-ESSMS evaluation, what is a central issue for the selection of tracer beneficiaries?

✅ Correct answer: c) To cover all the support modalities offered by the system.

📝 Explanation: The document emphasises the need to choose individuals whose backgrounds reflect the diversity of support methods to make the transformation of the offer and the coherence of the system visible (p. 5‑6).

Question 3

What does criterion 2.10.1 of the manual mainly correspond to in this document?

✅ Correct answer: b) The smooth and secure flow of information between professionals and partners.

📝 Explanation: The criteria table specifies that 2.10.1 questions how professionals share the information necessary for support, in relation to the continuity and quality of the journey (p. 8).

Question 4

In the DITEP example, which aspect is particularly highlighted for criterion 1.17.2?

✅ Correct answer: b) The ability to anticipate disruptions and mobilise appropriate partnerships.

📝 Explanation: The focus on 1.17.2 in DITEP shows that the evaluation concerns the system's ability to identify risks of disruption, adjust support, and mobilise internal and external partners to secure the journey (p. 10‑11).

Question 5

Which criterion in the manual is explicitly linked to the adaptation of professional skills to changes in the sector?

✅ Correct answer: d) 3.8.3.

📝 Explanation: The table indicates that criterion 3.8.3 concerns the adaptation of job management and professional pathways to changes in the sector and strategy, particularly inclusion, self-determination, and resource posture for the ordinary environment (p. 8).

8. Frequently Asked Questions (FAQ)

1. What types of ESSMS are covered by this document? (p. 2‑3)

   It targets all ESSMS engaged in a transformation of the offer, particularly integrated systems (DITEP, DIME, PCPE), territorial platforms, mobile team + accommodation groupings, or multi-ESSMS configurations under the same governance.

2. How does the document define "transformation of the offer"? (p. 1‑3)

   It defines it as the evolution towards medico-social, social, and health organisations based on personalised, modular, and coordinated pathways, enhancing self-determination, access to common law, and continuity of responses.

3. What are the two main axes of quality analysis in this context? (p. 3‑4)

   The first axis focuses on the personalisation of support and the empowerment of individuals; the second on the organisation of coordination and the securing of pathways at the territorial level, through cooperation and the prevention of disruptions.

4. How to select the tracked individuals in a transformed system? (p. 4‑6)

   The selection must reflect the diversity of support modalities (ordinary environment, accommodation, home, school inclusion, etc.), including in multi-ESSMS evaluations, in order to account for the modularity and continuity of pathways.

5. Which criteria from the manual are most directly related to the transformation of the offer? (p. 7‑8)

   The document highlights criteria 1.6.3, 1.17.1, 1.17.2, 1.17.3, 1.8.3, 2.3.2, 2.10.1, 3.4.1 to 3.4.4 and 3.8.3, which cover the collection of expression, disruptions, partnerships, inclusion, access to common law, information flow, and the adaptation of professional skills.

6. How to adapt the reading of criterion 1.17.2 in a DITEP? (p. 10-11)

   In a DITEP, the evaluation of 1.17.2 must take into account the diversity of modalities (PMO, day/night care, school and social inclusion) and assess the ability of the system to anticipate disruptions, adjust support, and mobilise partners to secure the pathway.

7. What is the role of governance in a multi-ESSMS evaluation? (p. 5-6)

   Governance must ensure cross-cutting management of the transformation: coordination of evaluation schedules, coherence of orientations, equity between components of the system, establishment of common procedures, and adaptation of skills to new pathway challenges.

9. Rewriting in Easy to Read and Understand (FALC) 

9.1. Title

Understanding the territorial coordination of support

9.2. Context and objectives (FALC)

• People want to choose their lives.

• They want to live like others.

• Services must help people make these choices.

• We no longer talk only about "places" in institutions.

• We talk about "pathways" that change according to needs.

• This document explains how to look at these pathways in the evaluation.

9.3. What the document provides (FALC)

• The document helps teams and evaluators.

• It provides simple questions to observe the pathways.

• It shows which criteria from the framework are important.

• It explains how to choose people for the tracers.

• It gives concrete examples of systems.

• It helps to see if the service works well with partners.

9.4. Key points in Easy Language

• The person must be at the centre of the project.

• Support must adapt to their needs and choices.

• Professionals must listen to the person and their relatives.

• Services must work with the school, the doctor, the town hall, and associations.

• It is important to avoid breaks in the person's journey.

• Evaluators look at how teams cooperate.

• They look at how information flows between professionals.

• They observe if the person can access activities in the city.

• They check if services help the person to exercise their rights.

• They look at whether teams are trained in new practices.