In 2021, The Collaborative partners are working together to pilot a new pathway for patients with dyspnoea due to congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD).
The new pathway will provide better links between Royal Melbourne Hospital and primary and community care services; build the capacity of GPs to manage patients in the community; and facilitate access to a Community Navigator to provide psychosocial supports that help drive better clinical and social outcomes.
The pathway aims to:
Improve the clinical management of patients with COPD and/or CHF in the community by supporting GPs to manage these complex patients through enhanced discharge summaries, clear management and escalation pathways to acute care, access to telephone advice from General Medicine doctors, and provision of support, education and training.
Improve the psychosocial management of patients with COPD and/or CHF in the community by providing access to a Community Navigator to undertake a psychosocial needs assessment and refer to a range of local community health and non-health services to help address social determinants impacting health and wellbeing.
Improve patient experience by linking existing pathways, improving information flows between professionals involved in a patient’s care, and by providing high-quality care, closer to home.
Clinical guidelines for the management of CHF and COPD
Eligibility criteria apply. The Hospital Admission Risk Program (HARP) and North Western Melbourne Primary Health Network (NWMPHN) teams will notify GPs when they have a patient enrolled into the pathway.
The outcomes that The Collaborative aims to achieve from the dyspnoea pilot in 2021 – 2022 are demonstrated by the following measures of success.
Measures of success
At 1 year
Increased patient and carer knowledge of condition/s
Improved ability of patients to self-manage
Increase in social prescribing and referral to community and non-health services
Identification of the key support services patients need to stay in community settings
Increased health professional knowledge of pathways for complex patients
Increased GP confidence managing COPD and CHF
Improved information exchange between health professionals
Reduced length of stay (decreased total bed days)
Long term outcomes
Improved patient experience and quality of life
Improved functional status of patients
Increased information exchange between acute, primary and community care
Improved understanding of available services between health professionals
More efficient use of services
Watch to learn more about how the dyspnoea pathway will help GPs.
Watch to learn more about eligibility and the role of navigators.
Resources for GPs
Resources for patients
For more information on the clinical management of dyspnoea, congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD), head to HealthPathways Melbourne, or browse the resources below: