The transition of western health care systems can be facilitated by Integrated Care (IC) approaches helping to diminish demographic challenges. The concept of clinical pathways is an approach for a more structured, overarching and broader care as it allows higher system efficiency, i.e. a better coordination of treatment especially for patients with complex diseases (co-morbidities). They can be sustained by Information and Communication Technology (ICT) that enables a better coordination and integration of patients within their care and social network. However, there is no broad use of such pathways as it lacks of a concept for the utilisation of a holistic pathway usage for the care of people with co-morbidities. The paper contributes by developing a framework for the design, handling and work of or with personalised dynamic pathways (PDPs). By suggesting the PDP-Framework, we aim at providing a concept that has the potential to improve the care. It also fosters the application of ICT-based care in terms of a concept for shaping ICT services. Our contribution builds the fundament for a multi-actor involvement along the care processes and facilitates the monitoring of the patients’ statuses, their activities and compliance with care measures
