Development and early evaluation of OPTIMAP: A digitally enabled nurse-led multidisciplinary pathway for care of people with severe obesity in a Public Australian Health Network

Public obesity services in Australia face significant challenges including long wait times, fragmented care pathways, limited clinical capacity, and high administrative burden. To address these barriers, the Central Adelaide Local Health Network (CALHN) Metabolic and Bariatric Clinic (CMBC) team developed OPTIMAP (Online Pathway from Triage to Individualised Metabolic Action Plan), a digitally enabled, nurse-led model of care designed to streamline triage, enhance patient activation, and improve multidisciplinary coordination for patients with complex obesity. We outline the development process of OPTIMAP and report early outcomes from the restructured CALHN CMBC. OPTIMAP was designed in partnership with clinicians, nursing leaders, CALHN Digital, Digivate Health, and the Personify Care platform. The pathway incorporates a digitally delivered active waitlist comprising comprehensive baseline assessment, modular obesity and obesity-related comorbidity education, behavioural tasks, red-flag monitoring, automated general practitioner communication, appointment reminders and confirmation tools. Clinician dashboards provide real-time visibility of patient progress, engagement, and risk indicators, enabling efficient preparation for personalised care. During the first three months post-implementation, clinic capacity increased by 138 % from a pre-implementation mean of 78 appointments per month to 171 appointments per month. Failure-to-attend rates decreased by 31 %, and clinician administrative burden reduced substantially, with direct clinical care time increasing from 29 % to 52 %. Digital engagement was high, with 82 % of patients completing the baseline assessment and over 2800 educational activities completed. Patient and clinician feedback was overwhelmingly positive. OPTIMAP represents a scalable method for integrating digital tools and nurse-led coordination to improve obesity-care efficiency and patient preparedness within public health systems.