Dyspnoea Pathway Pilot

The Collaborative’s new dyspnoea pathway is now available for primary care clinicians.

Breathe easier… resources for general practice are available below.

It will assist clinicians to manage patients experiencing dyspnoea (shortness of breath) due to congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD), who are at risk of multiple admissions to hospital.

Eligibility criteria apply. The Hospital Admission Risk Program (HARP) and North Western Melbourne Primary Health Network (NWMPHN) teams will notify GPs in writing when they have  a patient enrolled into the pathway.

Quick links

Use the following links or scroll down to find resources and more information about the pathway.

About the pilot

The Collaborative is a partnership between NWMPHN, The Royal Melbourne Hospital (RMH), cohealth and Merri Health, working together to create better pathways for people with complex chronic disease.

The dyspnoea pathway was launched on 16 August 2021 and is operating in a pilot phase for one year. The pilot aims to improve the patient experience, reduce hospital admissions, the length of hospital stays, and identify services that people need to stay well and treated in the community.

The pilot will trial a new pathway that:

  • better connects the RMH and primary and community care services
  • builds the capacity of GPs to manage their patients in the community
  • enables access to psychosocial support through community navigators, driving better clinical and social outcomes, and a better patient experience.

Better access, education and support for GPs

Through this pilot we can help develop and build the capacity of GPs to treat and manage patients more effectively in the community, rather than in hospital.

We have worked with the RMH, community health and local GPs to improve discharge information, and GPs can now call for advice from a general medicine doctor at the hospital when they need it.

The pathway also uses community navigators in community health services at cohealth and Merri Health to support people to stay well and connected – to improve their overall wellbeing.

Watch to learn more about how the dyspnoea pathway will help GPs.

Watch to learn more about eligibility and the role of navigators.

For GPs, this pilot will trial the new dyspnoea pathway, which aims to:

  • Improve the clinical management of patients with COPD and/or CHF in the community. It will support GPs to manage these complex patients through enhanced discharge summaries from RMH, 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 these patients in the community by providing access to a community navigator at cohealth or Merri Health. The community navigator will undertake a psychosocial needs assessment and refer to a range of local community health and non-health services.
  • Improve the 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.


Eligible patients will be enrolled during or after an admission to The Royal Melbourne Hospital. HARP will identify patients based on the criteria below and within capacity constraints. HARP will enrol and consent patients into the pilot and notify patients’ usual GP and the community navigators.

Eligibility criteria

  1. Geographic location (patient resides in Melbourne, Moonee Valley, Moreland, or Yarra local government areas).
  2. Dyspnoea affecting quality of life.
  3. Clinical diagnosis of COPD (asthma ruled out and lung function test required) or CHF (by echocardiogram). Note that only CHF patients from general medicine wards are eligible.
  4. Admitted to RMH at least once in the past 12 months and at risk of readmission.
  5. Not currently undergoing dialysis.

Note that for the first 6 months, patient numbers need to be kept within a capacity cap of 15 new patients per month.