About the project
The Assisted Self-Management pilot is a system-wide improvement initiative designed to support people with chronic conditions to stay well at home and avoid unnecessary hospital admissions.
This pilot will test a digitally enabled, patient-centred care model that combines clinician oversight and support with evidence-based self-management strategies.
The initiative aims to:
- empower patients with chronic obstructive pulmonary disease, congestive cardiac failure and/or diabetes to actively manage their health
- reduce avoidable hospitalisations and emergency presentations
- improve patient wellbeing and clinical stability
- support health services to deliver care aligned with value-based healthcare principles – focused on improving patient outcomes and strengthening partnerships between consumers and clinicians.
Background
Chronic conditions such as chronic obstructive pulmonary disease, congestive cardiac failure and diabetes are among the leading causes of avoidable hospitalisations in Victoria. These admissions can be distressing for patients and costly for the health system.
Without a consistent or connected model of chronic disease follow-up and secondary prevention across Victoria, many patients transition out of hospital without a coordinated, evidence-based plan for ongoing management, leading to high re-presentation rates and acute care burden.
Solution design
This pilot explores how a digitally enabled, patient-centred care model can enable safer, more sustainable care for people with chronic conditions.
The key components of the model are:
- proactive, personalised care
- integrated pathways
- data-driven improvement.
The model combines proven self-management strategies (like condition-specific education and symptom tracking) with clinician oversight, supported by a digital platform that triages patients, collects outcome data and provides tailored interventions.
Patients are risk-stratified into different care tiers, with high-risk individuals receiving remote monitoring and proactive support, while stable patients self-manage with regular check-ins and clear escalation pathways.
Participating health services will be supported to co-design and implement this model in a way that fits their context and populations. Early adopters will shape a scalable model for Victoria, with access to shared digital infrastructure, design, implementation and evaluation support.
Project milestones
This project is planned to be delivered from mid 2026 until December 2027, with a dedicated evaluation period extending until June 2028.
Participating health services
- Bayside Health (Alfred Care Group)
- Grampians Health
- Melbourne Health (The Royal Melbourne Hospital)
- Monash Health
- Northern Health
How to get involved
If you have any questions please contact staywellstayhome@safercare.vic.gov.au.
Priority area
This project supports our broader effort to reduce avoidable hospital admissions.