Essential Component 6
There are seamless transitions across all care settings

Patients, their families and carers often have to navigate unnecessarily complex systems of care that can change over time

Why is this an Essential Component?

Evidence for inclusion

As people approach and reach the end of life they, their families and carers are required to navigate increasingly complicated care systems to address their needs.

Current patient journeys are often poorly coordinated and this is particularly true for people with advanced chronic disease who have multiple comorbidities and a much slower and more unpredictable trajectory of functional decline (ACI, 2015)[1]. The needs of people, their families and carers during their end of life journey vary over time and care setting, meaning services need to be responsive, coordinated and flexible in meeting these changing needs.

It has been demonstrated that navigation support and or care coordination improves clinical outcomes and the experience and satisfaction of patients, families and carers.

A strong collaborative approach to care has been shown to not only increase patient satisfaction, patient care quality and optimise the use of finite resources, but is also likely to reduce errors, limit gaps in care and lessen unnecessary treatments and hospitalisations (NSW Health, 2019[2]; Palliative Care Australia, 2018[3]).

Provision of safe healthcare requires a synergistic approach with an emphasis on shared case management, effective communication, data sharing and teamwork between multidisciplinary professionals across all healthcare settings. A lack of continuous collaborative care is a contributing factor in adverse patient events (NSQHS, 2017)[4].

Intended beneficial outcomes

  • People are able to receive care aligned with their goals as they transition between settings of care (i.e. hospital, home, aged care).
  • Care is well coordinated and support is provided to patients, families and carers to assist in navigating health and community care systems.
  • Care providers across all settings understand their unique roles and are skilled in providing care to people as they approach and reach the end of their lives.
  • Clinical handover of care is optimal and supported by clear communication and clinical tools.
  • Changes in care requirements are identified and responded to appropriately.
  • Formalised referral and access arrangements support transitions of care.
  • Clinical information to support seamless care is available at the point of care.
  • Transfer of care occurs in consultation with patients, families, carers and care providers across all settings.
Patients, their families and carers often have to navigate unnecessarily complex systems of care that can change over time

What tools/resources could support the implementation of this component?

The Agency for Clinical Innovation conducted a review of the tools and resources supporting this component in 2021. The review identified local, national and international tools and resources that could be used to support the implement this essential component. None are specifically recommended or advised to be used in preference over another.

Click the Acknowledgement button below to view the working group members involved in the latest review.

Working group members

Name Role/Organisation

Dr Stephen Ginsborg

General Practitioner, Northern Beaches; Board member, Sydney North PHN, Council on the Ageing (COTA NSW), Community Care Northern Beaches, & Manly Warringah Division of GP

Working Group Co-Lead

A/Prof Joel Rhee

Associate Professor of General Practice, University of Wollongong; General Practitioner, HammondCare Centre for Positive Ageing+Care; Chair, RACGP National Faculty of Specific Interests - Cancer and Palliative Care Network

Working Group Co-Lead

Tamara Hollman

Clinical Nurse Consultant Palliative Care, Western NSW LHD

Jennifer Kasule

Registered Nurse, Sydney LHD

Renee Millen

Paramedic Educator for Palliative Care, Ambulance NSW

Kerrie Noonan

Clinical Psychologist & Social Researcher, Macquarie Health Collective

Hema Petal

Primary Care Advancement Coordinator, Sydney North Health Network

Victor Rocha

Improvement Facilitator, Palliative Care Outcomes Collaboration (PCOC)

Helen Smith

Nurse Practitioner, Silverchain Western Sydney LHD

Close acknowledgements

Core palliative care tools

Exploratory analysis of barriers to palliative care: Literature review

An Australian Government Department of Health commissioned literature review (2019) exploring the barriers and enablers of access to palliative care.

Facilitators and barriers to general practitioner and general practice nurse participation in end-of-life care: systematic review

Rhee JJ, Grant M, Senior H, et al. Facilitators and barriers to general practitioner and general practice nurse participation in end-of-life care: systematic review, BMJ Supportive & Palliative Care Published Online First: 19 June 2020. doi: 10.1136/bmjspcare-2019-002109

Groundswell Project

The Groundswell Project works with individuals, organisations and communities to improve how people in Australia die, care and grieve.

National rapid discharge guidance for patients who wish to die at home

The aim of the Rapid Discharge Guidance is to facilitate a safe, smooth and seamless transition of care from hospital to community for dying patients who wish to die at home rather than in a hospital or hospice. Last revised in December 2019.

PalliAGEDgp and PalliAGEDnurse

The palliAGED apps provide nurses and GPs with easy and convenient access to information to help them care for people approaching the end of their life. Timely access to palliative care information can support the clinical care being provided. An online-offline capacity means they can use the apps anywhere in Australia. As the app is web-based, it can be updated as new evidence and resources are released.

Palliative Care Outcomes Collaboration (PCOC)

The PCOC program is a framework and protocol for routine clinical assessment and response to palliative care. The program helps in identifying and responding to patient needs generating consistent information to plan and delivery care.

The Advance ProjectTM – supportive care assessment + referral triage tool

The Advance ProjectTM is a practical, evidence-based toolkit and a training package, specifically designed to support Australian general practices to implement a team-based approach to initiating advance care planning (ACP) and palliative care into everyday clinical practice.

Using Resuscitation Plans in End of Life Decisions

NSW Health policy directive prescribes the standards and principles of care for appropriate use of Resuscitation Plans by NSW Public Health Organisations for patients in hospital for 29 days and over. A Resuscitation Plan is a medically authorised order to use or withhold resuscitation measures and which documents other aspects of treatment relevant at end of life.

Case conferences / family meetings

Family meetings in palliative care: multidisciplinary clinical practice guidelines

Guidelines for health professionals working with cancer and palliative care patients developed by the Centre for Palliative Care Education and Research in 2009.

Multidisciplinary Case Conferences

Commonwealth Government specifications for MBS payments for multidisciplinary case conferences.

Multidisciplinary meetings for cancer care: A guide for health service providers

National Breast Cancer Centre produced guide (2005) for health service providers and multidisciplinary team members with ideas and tools to improve multidisciplinary care at a local level.


Core Palliative Care Medicines List for NSW Community Pharmacy

State-specific core medicine list for NSW community pharmacy developed by NSW Health.

palliMEDS app 

Based on the ANZSPM core medicines list.

Prescribing S8 Medications in NSW

Any injectables, or hydromorphone for 2 months or more requires a written authority from NSW Health.

Symptom Management Medicines for Australian Living in the Community and in Residential Aged Care Facilities (RACFs)

Australian & New Zealand Society of Palliative Medicine Palliative Care (ANZSPM) core palliative medicines list.

Older people

Care coordination of patients in RACF with palliative care needs

palliAGED developed resource for care coordination (last updated 2017).

RACGP Best Practice Guide for Collaborative Care between General Practitioners and Residential Aged Care Facilities

This guide (2013) serves to provide GPs, general practice staff and RACF staff with advice regarding best practice for collaborative arrangements for the care of older persons (‘residents’) in RACFs in Australia, and has been designed to be read in conjunction with the RACGP (silver book) Medical care of older persons in residential aged care facilities.

RACGP Silver Book - palliative care approach

Medical care of older persons in residential aged care facilities, a Royal Australian College of General Practitioners (RACGP) publication commonly known as the Silver Book. Last revised in 2020.


  1. NSW Agency for Clinical Innovation. Intergrated care for older people with complex health needs. Sydney: ACI Aged Health Network; 2013.
  2. NSW Ministry of Health. NSW Health End of Life and Palliative Care Framework 2019-2024. Sydney: NSW Ministry of Health; 2019.
  3. Palliative Care Australia. National Palliative Care Standards (5th edition). Canberra: Palliative Care Australia; 2018.
  4. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards (2nd edition). Sydney: ACSQHC; 2017.

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