Dyspnoea Pathway Pilot

The Dyspnoea Pathway pilot has now transitioned to existing care coordination and navigation services run by cohealth and Merri Health.  

It was a collaborative initiative which ran from August 2021 to August 2022. It was designed to provide psychosocial support to patients living with chronic obstructive pulmonary disease (COPD) or chronic heart failure and experiencing dyspnoea, or shortness of breath.  

The project will now transition into existing programs within cohealth and Merri Health services. Patients will receive the same successful model of care, with a new referral route.  

The Collaborative is a partnership between The Royal Melbourne Hospital (RMH), Merri Health, cohealth and North Western Melbourne Primary Health Network to improve local care services for people living with chronic illnesses.

For more information, visit the Collaborative website.

About the pilot

Following an inpatient stay at the Royal Melbourne Hospital (RMH) and support from the RMH Hospital Admission Risk Program (HARP), clients with ongoing psychosocial needs were given access to a qualified social worker operating as a care-community navigator. The navigator and client completed a needs assessment and developed a support plan to connect to local services. These included financial support, social participation groups, food supports, travel and psychological support services. This process is often called social prescribing.  

The pilot activities, and overall expected outcomes, were greatly reduced due to the COVID-19 pandemic.   

By connecting with others and developing supportive relationships, clients improved their quality of life. Health care workers participating in the project reported that they expanded their knowledge of existing services and established cross-organisational relationships.  

How to access this service

This service is now managed by existing cohealth and Merri Health services. You can find more information below. It is available for clients with any chronic illness, including COPD and heart failure. Clients can access a social worker, complete a needs assessment, set goals and start accessing local support services. Access will depend on where clients live. 

Merri Health’s Living Well Aging Well

What is it?

This service provides access to trained social workers functioning as community navigators who connect clients with services and activities that improve quality of life. This includes:  

• individualised assessment and support  
• identification and reduction of barriers to social connection  
• connection to support services, which may include financial, health, community activities, neighbourhood houses, and access to seminars groups and workshops. 

There may be costs associated with some of the services.  

For more information, visit: Merri Health Living Well, Ageing Well at 50+ 

Who is it for?

This service is available for people:  

• 50-64 years of age 
• living in the northern metropolitan region of Melbourne  
• not receiving other government support funding such as the NDIS  
• have chronic health issues, or a lack of confidence in accessing their community who are time-poor carers unaware of available social and community resources.  

How to refer or self-refer

To refer a client, fill out the referral form (.pdf)

• Email: LivingWellAgeingWell@merrihealth.org.au
• Call: 8319 7408 

To refer clients over 65 years of age:

• Email: kate.cinerari@merrihealth.org.au
• Phone: 9304 9220

Visit HealthPathways Melbourne for more information on chronic illnesses, including Dyspnoea.

cohealth’s Care Navigation

What is it?  

This service provides access to trained social workers, known as care navigators, who connect clients with services and or activities that can improve the quality of life. It provides:  

• short term support (under 3 months)  
• individualised assessment and support  
• identification and reduction of barriers to social connection  
• connection to support services which may include financial, health, community activities, neighbourhood houses, and access to seminars groups and workshops. 

There is no cost for this service. 

Who is it for?  

This service is available for people who are:  

This service is available for people:  

• living in the inner or western Melbourne area  
• unable to access services due to physical or cognitive capacity, psychosocial barriers, language barriers or sensory deficits, or do not have friends or family to assist them.
• in need of support to access community supports and services including: 
  • • NDIS or My Aged Care  
    • neighbourhood houses  
    • community health services 
    • social support programs 

How to refer: 

Referrals can be sent to:

• Email: ServiceAccess@cohealth.org.au
• Phone: 9448 5521 

For more information, call: Odelia Malka, Care Navigator on 9448 5844.

Visit HealthPathways Melbourne for more information on chronic illnesses, including dyspnoea

Case study

Terry is a 62 year-old man with health conditions including chronic heart failure. He lives alone, and was referred to the program for support to link into community programs.

Terry was very open about his needs throughout the psychosocial assessment process. It revealed that he would benefit from financial and material aid, access to community transport and, because of social isolation, social support due to his feelings.

The community navigator sent referrals to a financial counselling agency and community transport, linked Terry into local foodbanks, and provided him with information on phone-based social support programs.

Terry feels confident to access food relief supports. With the assistance of community transport he is also able to access his community and health appointments at a very low cost. He is able to reach others over the phone when he feels like a chat. This provides him with company and sense of connection.