What are models of aged care palliative care?
A model of care broadly describes how health services are organised and delivered. [1] Models of palliative care typically involve multiple components and are defined by who provides care, to whom, what type of care is delivered, the setting, timing, duration, and how care is provided (e.g. virtually). [2]
At the end of life, individuals and their families often require support from multiple services. The structure of the care model, and how well services are integrated within it, can influence the quality and coordination of care. [3,4] While many different models of palliative care exist, there is no single model universally agreed upon. [5] However, the evidence suggests that palliative care is beneficial, regardless of the setting of care, with no associated negative outcomes. [2]
In aged care settings, models of palliative care often embed a generalist palliative approach into routine care, supported by timely access to specialist advice when needed. The focus should be on anticipating, recognising, and responding to palliative needs, rather than relying solely on external palliative care teams. [6]
Why these models matter in aged care
As the population ages, with more people living with multiple conditions and dementia, aged care settings are increasingly central to providing palliative care. However, aged care services operate at the intersection of health and social care systems, which creates challenges in communication, handover, and continuity. This can undermine timely recognition of palliative needs and the coordination of appropriate care. [6]
An effective model of care can address these challenges by clarifying roles, streamlining clinical pathways, and integrating external and internal supports. Effective approaches can also reduce ineffective treatments, help people achieve a comfortable end of life which reducing care costs. [7] Strengthening integration between services and building internal capability within aged care settings is therefore a key priority. [6]
The Aged Care Quality Standards require providers to have systems and processes in place that support coordinated, multidisciplinary clinical care services. (Outcome 5.4: Comprehensive care). This includes the responsibility to:
- Communicate and collaborate with others involved in the individual’s clinical care services (Action 5.4.4b)
- Facilitate access to after-hours and urgent clinical care services (Action 5.4.4c)
- [Enable] access to specialist palliative care and end-of-life health professionals when required (Action 5.7.3f).
Residential aged care providers are further charged with ensuring that older people have access to other services when the facility is unable to meet the individual’s needs (Action 7.2.2). This may require ongoing collaboration with specialist health services, including specialist dementia care services (Action 7.2.3). [8]
What the evidence tells us
Improving access to high-quality palliative care in aged care requires embedding a palliative care approach as core business. National reform efforts already support this direction, including the Comprehensive Palliative Care in Aged Care measure (‘the Measure’)—an Australian Government initiative launched in 2018-19. Delivered through matched funding with state and territory governments, the Measure supports innovative, tailored models of care to enhance end-of-life care in residential facilities. Its aims include improving the quality of care, increasing access to support, and enabling people to die in their preferred setting. [8]
The Measure has funded a range of models of care with shared priorities:
- Embedding in-reach services to support early identification of palliative care needs
- Building staff skills and confidence through ongoing education and mentoring
- Strengthening coordination between care teams and external providers
- Using performance data to monitor and drive quality improvement.
Early evaluation findings show that these models are most effective when adapted to local contexts, organisational priorities, and workforce capacity. There is no one-size-fits-all model, with success dependent on flexibility, collaboration, and alignment with the needs of each aged care service. [6]
Residential aged care models of palliative care
Residential aged care is a particularly complex setting in which to deliver palliative care, and there is limited high-quality research on which models are most effective. [9] Studies report that organisational barriers such as high staff turnover, insufficient training, and limited access to specialist services frequently undermine quality of care. Effective integration between aged care staff, general practitioners, and external palliative care providers is essential but often difficult to achieve. [1]
A scoping review identified four dominant models of palliative care in residential aged care settings. [10] These are as follows:
External specialist end-of-life care model
In this model, palliative care is delivered by an external specialist team during the terminal phase. This is shown to reduce hospitalisations and improve family satisfaction but does not support early or ongoing care and limits continuity.
An example of this care might be in-reach geriatric medicine work. In Australia, about 60% of these services provide in-reach geriatrician and nurse support for acute medical problems to residential aged care facilities. [11]
In-house end-of-life care model
Terminal care is provided by aged care staff who have received training. While this supports continuity, it may lack the specialist input needed for complex care.
In-house capacity-building model
Aged care staff are trained to deliver a palliative approach across the illness trajectory, not just during the final days. This involves identifying clinical leaders, educating all staff, and embedding continuous improvement processes. Evidence shows benefits including increased advance care planning, reduced hospitalisations, better staff retention, and higher family satisfaction.
Hybrid model (in-house care with external support)
This model combines internal staff capacity-building with ongoing input from specialist palliative care teams, such as nurse practitioners or specialist nurses. It is consistent with structured frameworks like the Gold Standards Framework and has been associated with improved planning, reduced inappropriate hospital use, and better symptom control. [10]
Palliative Care Needs Rounds (hereafter ‘needs rounds’) are an example of this hybrid in-reach support model and the most implemented as part of the Australian Government’s Measure initiative. [6] Needs rounds are monthly hour-long staff-only triage meetings to discuss residents at risk of dying without a plan in place. They are chaired by a specialist palliative care clinician and attended by care home staff. A checklist is followed to guide discussions and outcomes, focused on anticipatory planning. [12]
Needs rounds have a strong evidence base. [13] Studies of their outcomes show:
- An increased number of documented advance care plans [14]
- A substantial reduction in the length of hospital stays and a lower incidence of death in the acute care setting. [15]
- Improved quality of life and death for care home residents [16]
- Enhanced staff skills and confidence in symptom management, communications with general practitioners and relatives [16]
- Strengthened relationships between care home and specialist palliative care staff. [16]
Under the Comprehensive Palliative Care in Aged Care Measure, needs rounds were tailored to meet the specific requirements of various regions and facilities. For example, Tasmania implemented ‘mini needs rounds’ due to resource limitations and involved GP registrars to enhance medical trainee palliative care competencies. Needs rounds have also been adapted based on geographic contexts such as telehealth-facilitated needs rounds in the Northern Territory and other remote areas. [6] In metropolitan South Australia, they were led by palliative care nurse practitioners alongside specialist nurses and clinical leaders. Conversely, in South Australian regional and rural settings, medical consultants spearheaded the rounds with participation from senior nursing staff, GPs, and pharmacists. [17]
Challenges identified by needs rounds trials include time constraints for external providers and sustainability beyond pilot funding. Medical-led models may be more difficult to sustain in rural areas due to the cost and availability of medical consultants, while nurse-led models have been seen as more adaptable. [17] Nonetheless, needs rounds appear to be feasible, valued by staff, and adaptable to local contexts. [16]
Some older people will enter residential aged care to receive time-limited, planned palliative care. This care will be supported by AN-ACC Class 1 funding and eligible recipients will have been assessed by an independent medical or nurse practitioner as having an Australia-modified Karnofsky Performance Status (AKPS) score of 40 or less and/or a life expectancy of less than three months. [18]
Home and community-based models of palliative care
Home and community-based palliative care models are designed to support older people to remain at home and avoid unnecessary hospital admissions, particularly in the final stages of life. These models are typically led by general practitioners and community nurses in collaboration with aged care teams, family carers, and, when needed, specialist palliative care services. [19]
Key components of these models include early identification of palliative care needs, advance care planning, and strong communication and coordination between providers. Shared care arrangements and case management are often used to enhance continuity of care, while additional supports such as after-hours services, hospital-in-the-home, and telehealth help manage deterioration and reduce avoidable hospital transfers. [1,20]
There is reliable evidence, particularly for cancer populations, that home-based palliative care reduces symptom burden, increases the likelihood of dying at home, and improves satisfaction among families and carers. [21] However, findings are less conclusive for older people with non-cancer conditions such as dementia or frailty. [1]
In home care settings, families often bear the brunt of care responsibilities. Models that support family carers—through education, anticipatory guidance, and bereavement care—contribute to a more positive end-of-life experience for both the person and those close to them. [22]
As of 1 July 2025, the Support at Home Program includes an End-of-Life Pathway for people who are expected to live for three months or less. It provides access to more intensive in-home aged care services to help people stay at home for as long as possible. Individuals can be referred for a high-priority assessment to access this support, even if they are not already in the Support at Home Program. Up to $25,000 in funding is available which must be used within 12-16 weeks. The pathway will work alongside, not replace, support from specialist palliative care services. [23] The success of this funding model will depend on the availability of appropriate home care provider supports and services and the ability to access nurses with palliative care skills as demand grows. [24]
Training and capacity-building approaches
Most palliative care in aged care models share a strong focus on building skills and confidence through education. Training covers symptom management, recognition of deterioration, and communication around dying. [6] The following are examples of Australian palliative care training, capacity, and evaluation models in aged care.
Palliative Care Needs Rounds
Needs rounds provide an opportunity for case-based learning, particularly when they include structured discussions about residents at risk of deterioration or in the last stages of life. [14]
The Palliative Aged Care Outcomes Program (PACOP)
PACOP is a national framework and infrastructure supporting the delivery and improvement of palliative and end-of-life care within aged care settings. It functions as a practice support model that helps aged care services embed systematic and standardised assessment, quality improvement, and staff development into everyday care — key features that underpin effective palliative care models. [25]
ELDAC Linkages Program
This is a national initiative designed to improve the delivery of palliative care and end-of-life care within aged care services by strengthening formal and informal partnerships between aged care organisations and external health care providers. The program supports residential aged care services and home care providers over a 6 to 12-month period to build collaborative relationships with general practitioners (GPs), specialist palliative care services, Primary Health Networks (PHNs), and hospitals, with the goal of embedding a palliative approach into routine care. [26]
Other models
Virtual care
Virtual care models, including telehealth and videoconferencing, have become increasingly important in supporting aged care, particularly in rural and remote areas. They can also reduce hospital transfers from residential aged care facilities by enabling facility staff to provide in-facility care with support from an emergency department. [27,28] During needs rounds, telehealth allows external professionals, such as GPs and pharmacists, to participate in meetings they would otherwise not attend due to travel constraints. [17]
Virtual care came to the fore during the COVID-19 pandemic. [29] In one Australian model established at this time, virtual rounds were used daily to facilitate clinical engagement and coordination of care between residential aged care staff, hospital in-reach services, and external palliative care services. [30] Health-related characteristics—including disability, chronic disease, and multimorbidity—were found to be predictors of telehealth uptake in older Australians during COVID-19. However, tailoring virtual models to meet the needs of older people, including support for digital access, is essential. [31]
Pop-up model
Palliative needs in rural areas can be specific or intermittent without a permanent infrastructure being warranted. A pop-up model can recognise gaps in local services and be used to respond to specific palliative needs. [1] An example of this is Torres and Cape Hospital Health Service in Queensland which has consulted with communities to create a pop-up model of care implementing new resources, a needs rounds model of palliative care and a bereavement model for families. The program plays a coordination role between palliative care services and residents. [6]
Shared care
The shared care model recognises that no single provider or team can meet all the needs of an older person, especially as they approach the end of life. Instead, shared care aims to integrate expertise from across the health and aged care systems in a coordinated, person-centred way with joint multidisciplinary responsibility for planning and delivering care. [1] It is characterised by ongoing communication and information-sharing across services. In aged care this might mean:
- Residential aged care staff provide day-to-day generalist care
- GPs oversee medical management and prescribe treatments
- Specialist palliative care teams provide advice, in-reach support, or direct care as needed.
Integrated care
Integrated care aims to bridge fragmented systems by aligning services across funding, governance, and delivery levels. Integration operates at multiple levels—clinical, organisational, and funding—and is intended to improve consistency, efficiency, and the experience of care. An example from The Measure initiative is the work of the Metropolitan Palliative Care Consultancy Service in embedding hospital-based nurse liaisons to support transfers of older people between hospital and residential facilities. This initiative aims to smooth the transitions of residents between the two sites of care and minimise the use of acute hospital resources [6]
Challenges within models
Workforce limitations
One of the most frequently cited barriers to implementing effective palliative care models in aged care is the workforce itself. Many staff working in residential aged care do not hold formal palliative care qualifications, and turnover remains high across all staff levels—including personal care workers, registered nurses, and facility managers. This instability undermines efforts to build and sustain in-house palliative care capability and limits the long-term effectiveness of education and training initiatives. [22]
In many facilities, there is also a limited number of registered nurses available to provide clinical supervision, which poses challenges for maintaining palliative care quality, especially in facilities attempting to implement more complex or integrated models. For in-reach programs, there is often a shortage of available specialist palliative care clinicians to support ongoing engagement. [6]
Limited integration and poor information sharing
Many services operate in silos. Coordination between residential aged care staff, GPs, hospitals, and specialist palliative care teams may be ad hoc and reliant on the strength of individual relationships. [6] Fragmented service delivery—particularly across aged care, primary care, and specialist services—can result in inconsistent symptom management, poor communication, and reactive rather than proactive care. Transitions between care settings are especially vulnerable to breakdowns due to poor clinical handover and lack of shared documentation. [22]
Page updated 04 April 2025