Asthma affects 2.8 million Australians and remains a major cause of preventable hospitalisation. At Northern Health (NH), rising referrals and wait times of up to 289 days meant patients at highest risk of deterioration were often waiting alongside those with stable disease. Traditional referral processes were unstructured, triage was limited, and clinicians lacked critical information at first review. Care was episodic and reactive rather than continuous and proactive.
In response, NH launched Australia’s first Severe Asthma (DCP): a co-designed, value-based model that redefines the full cycle of care for people with severe or poorly controlled asthma.
The DCP was developed in partnership with eight consumers with lived experience, alongside respiratory physicians, nurses, pharmacists, respiratory scientists and digital specialists. Through structured workshops, patients defined what successful care looks like: better symptom control, reduced anxiety, clearer communication, and fewer emergency visits. These priorities shaped pathway design, outcome selection and digital functionality.
At referral, patients complete a structured digital questionnaire aligned with Global Initiative for Asthma (GINA) guidelines, capturing exacerbation history, corticosteroid use, comorbidities and validated patient-reported outcome measures (PROMs). This enables true risk stratification before the first appointment, ensuring those most likely to deteriorate receive timely review.
Patients are onboarded to the My Health@Northern app, which provides multilingual education, digital asthma action plans, symptom tracking and secure messaging. Continuous PROM monitoring, including Asthma Control Questionnaire (ACQ-5), Patient Activation Measure (PAM) and Hospital Anxiety and Depression Scale (HADS), enables early identification of deterioration. Rule-based alerts prompt proactive outreach, shifting care from reactive to anticipatory.
The initiative has currently supported 304 patients to date, representing 80% of the severe asthma service cohort. Since implementation:
• Average wait times reduced from 289 to 159 days
• Failure-to-attend (FTA) rates reduced from 23% to 17%
• 57% of patients reported improved asthma control
• 72% demonstrated stable or improved activation levels
• Clinic efficiency has been maintained without additional staffing
Importantly, initial development of the DCP was supported through grant funding and in-kind organisational expertise; however, implementation and transition to business-as-usual were achieved within existing activity-based funding arrangements. No additional clinic hours or staff were required. By reducing preventable emergency presentations, optimising biologic targeting, and embedding structured triage, the pathway improves outcomes while strengthening system sustainability.
The Severe Asthma DCP demonstrates that value-based healthcare can be operationalised in routine public hospital practice. It integrates co-design, outcome measurement, digital enablement and multidisciplinary care within a single Integrated Practice Unit. The model is now embedded as standard practice and is being extended to other chronic conditions.
This initiative shows how a digitally enabled, person-centred redesign of care can deliver measurable improvements in health outcomes, patient experience and resource stewardship across the full cycle of care.