Palliative care pathways and frameworks in Primary Health Care

There are a number of established pathways and frameworks that are in current use within the Primary Health Care setting that you might be able to adapt for local use.

Deciding which pathway or framework to use

The identification of a person with life limiting illness' palliative care needs becomes the starting point for initiating a palliative approach or end-of-life care. There is no prescribed pathway for care as the needs and preferences of individuals will vary as the person's physical, spiritual, environmental, emotional characteristics determine the composition of the multidisciplinary team that supports them.

There are practical, pathway-related resources that can help with the delivery of palliative care in the primary care context. These often include referral triggers to other PHC services and to acute based specialist and emergency services. While individual palliative care trajectories are unique there are several pathways which can be used to guide their care.

Being flexible within a care pathway is key to providing appropriate end-of-life care

Some examples of population specific pathways developed for the PHC context are provided below. CareSearch, GP, Nurses, and Allied Health Hubs also provide you with useful information and tools to assist with palliative care delivery, no matter which pathway you decide to use.

Example palliative care pathway options 

Pathways for older people

The Royal Australian College of General Practitioners (RACGP) ‘Silver Book’ provides General Practitioners with guidance on the care of older people, by providing information on what to do at different points in time.

The palliAGEDgp (soon to be replaced by the CareSearchgp App) smartphone app provides evidence-based information to GPs who are caring for older people living at home or in residential care.

Health pathways

Health pathways provide a model of working with other health professionals to improve outcomes and patient journeys. The pathways are customised to local services by local health professionals including General Practitioners. The End of Life Directions for Aged Care (ELDAC) HealthPathways page provides an easy way to find a palliative care pathway within your local area.

MBS remuneration to support a planned general practice palliative care pathway

A practical palliative care pathway linked to Medicare remuneration can guide General Practitioners in reimbursement within the primary health care setting. Developed by North Western Melbourne PHN, there are pathways for home care and residential aged care.

MBS Items to Support a Planned GP Palliative Care Pathway (RAC) (230kb pdf)

MBS Items to Support a Planned GP Palliative Care Pathway (Home) (231kb pdf)

Gold Standards Framework

The Gold Standards Framework was developed in the United Kingdom to provide a systematic approach to introducing best practice care for people nearing the end of life. This is achieved through care coordination and a quality improvement lens to care provision. Knowing how to implement a gold standard framework can help to ensure all people living with life limiting illness receive continuity of care. This framework highlights a coordinated programme of care for people in the last 12 months of life irrespective of diagnosis, identifying key actions to support its implementation according to setting including primary care.

Rural and remote population model

The Far West NSW Palliative and End-of-Life Model of Care was developed within the Far West Local Health District and provides a useful guide to needs based care of people with life-limiting disease in the last year of life. The model is for generalist services, to enable a consistent and quality palliative approach.

Referral triggers

While General Practitioners are well placed to provide and coordinate much of this care, knowing how and when to refer to other health professionals to build a care pathway for a patient is important and will assist the patient to remain at home or in a residential aged care facility. Read more on our Referral page.

Care transitions

Knowledge of referral triggers and care pathways will assist with coordinating care across the health system and establish collaboration with other health care providers. Read more on our Care Transitions page.

Last updated 06 February 2024