Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
Caring@home promotes culturally responsive care, ensures equitable choices, and empowers clinicians, carers and families to support end-of-life care at home.
Dates: March 2025 - February 2026
Implementation sites: Brisbane South Palliative Care Collaborative
Partnerships: Ageing Australia, ACRRM, APNA, BSPHN, NAATSIHWP, PCA, PSA
Aim
Caring@home aims to increase access to high-quality and timely end-of-life care for people based at home by developing practical and evidence-based resources and delivering education for clinicians.
Outcomes
- Measurable improvements in clinician capability, confidence and intention to change practice in provision of palliative care in the community
- Engagement with and upskilling of the primary care sector to improve accessibility to palliative care in the community
- Improved community access to medicines to treat terminal symptoms
- GPs engaging in quality improvement to contribute to more proactive and improved quality of end-of-life care provision
- Enhanced quality and consistency of end-of-life care delivered to home-based patients
- Evidenced high uptake of, and positive feedback about resources for services, health professionals, families and carers
- Framework for end-of-life care incorporated into national publications, websites and PHN HealthPathways
Background
As Queensland's population ages, the number of people living with incurable and life-limiting illnesses requiring support in community settings is increasing. Most of these people will die an expected death (1). Aged care reforms (2) and new funding models (3) have prioritised reducing avoidable hospital admissions and supporting people to die at home when that is their choice.
Most Queenslanders say they would prefer to die at home (4), and for some First Nations peoples this may mean returning to and dying on Country, where cultural, spiritual, and family connections are often strongest. Despite these preferences, dying in Queensland remains largely institutionalised, with many people still dying in acute care settings (5).
Enabling more people to die at home when that is their choice benefits not only individuals, but the Queensland health system overall (6). It requires embedding personalised, proactive, evidence-based end-of-life care into routine practice of primary care services. Primary care encompasses general practice, community nursing, community aged care, Aboriginal and Torres Strait Islander health services, Royal Flying Doctors Service (RFDS), ambulance services, allied health and pharmacy.
Problem to be addressed:
- The caring@home project was established to address the gap between the number of people wishing to die at home and the number of people able to do so.
Key contributing factors to this problem were identified to be:
- gaps in knowledge and skills among primary care providers in delivering home-based palliative care
- lack of identification of approaching death (and thus a lack of proactive planning - if a person does not know that they are dying, they will not plan for it)
- delays in symptom management
- limited access to palliative care medicines in the community.
To address these barriers, caring@home recognised the need for:
- upskilling of primary health clinicians
- standardised palliative care practices in the community setting
- proactive planning for individuals with terminal diagnoses
- palliative care that respects and embraces cultural diversity
- equitable access to medicines to treat terminal symptoms
- stronger collaboration between services and disciplines
- timely symptom management provision in community settings
- digital and virtual innovations to support clinicians, particularly in rural and remote locations
- free, accessible information to support family carers.
Objectives of the caring@home project:
- Improve access to quality palliative and end-of-life care for home-based patients, including those from underserviced populations
- Strengthen clinician capability to deliver a standardised best-practice approach to care and symptom management for home-based palliative patients
- Empower families and carers, inclusive of those from underserviced populations, to help manage palliative and end-of-life physical symptoms
- Enhance the overall quality and consistency of palliative and end-of-life care delivered to home-based patients.
Methods
Caring@home adopted a multifaceted, co-design approach to develop evidence-based clinical tools and resources, embedding standardised best-practice approaches within primary care, and supporting implementation through education and quality improvement strategies.
A National Steering Committee, Education Advisory Committee and First Nations Advisory Committee were convened. Membership included palliative care clinicians, GPs, NPs, nurses, pharmacists, aged care representatives, Aboriginal and Torres Strait Islander health clinicians, peak bodies and government stakeholders. Engagement of clinicians and consumers across metropolitan, rural and remote Australia enabled diverse perspectives and strong stakeholder ownership. Collaboration with other national palliative care projects ensured alignment with interjurisdictional standards and avoided duplication.
caring@home developed resources at three levels:
1. Clinical service level (systems and policy)
- Guidelines for the handling of palliative care medicines in community services
- Example policy and procedures: Supporting carers/families to help manage breakthrough symptoms safely using subcutaneous medicines in the home
- National Core Community Palliative Care Medicines List - identifies four core palliative medicines to manage common terminal-phase symptoms for home-based patients requiring urgent symptom relief. Community pharmacies that stock these medicines can update their listing on the National Health Services Directory to include 'Palliative medicine services' as a service offering.
2. Clinician level (clinical tools to support best practice)
- Prompts for End-of-Life Planning (PELP) Framework - supports clinicians to deliver high-quality person-centred care in the last 12 months of life
- Terminal Care Planning Checklist for nurses in the community - identifies actions required to prepare care for a person at home in their final hours, days or week.
- Audit tool: End-of-life Planning - supports quality improvement in caring for people in their last year of life
- palliMEDS app - supports primary care prescribers to provide optimal symptom management to their patients in the community.
3. Carer and family level (capacity building)
- Community Palliative Care Resources box - free resources for clinicians to use to teach carers and families how to manage care, symptoms, and subcutaneous medicines safely
- Community Palliative Care Resource Pharmacy Pack - for pharmacists to use to support carers and families with managing care and symptoms
- Resources for Aboriginal and Torres Strait Islander Families - for health professionals to use to support Aboriginal and Torres Strait Islander families helping to provide end-of-life care at home
- Apps and videos to support symptom management and practical care at home, including culturally responsive resources for First Nations families.
Implementation combined education, communication and quality improvement approaches. Education was delivered through online modules, CPD activities, workshops, webinars and conference presentations. Digital platforms ensured accessibility for rural and remote clinicians.
A national rollout included newsletters, conference engagement and sector partnerships. The inclusion of audit tools enabled services to embed continuous quality improvement.
Evaluation was integrated into all education activities through post-session surveys, and user feedback from services who received resources. Resource utilisation metrics and service-level feedback informed iterative refinement.
Discussion
The caring@home initiative, funded by the Australian government, continues to offer free, innovative resources for use by health professionals to support carers and families. The resources have been widely promoted and distributed across Queensland and are also easily accessible online and on the caring@home app / caring@home Indigenous app. Their simple format, readability and impressive visual appeal have ensured relevance to people with varying levels of health literacy, including those from culturally and linguistically diverse backgrounds and individuals with language, literacy or communication barriers. Collaboration with remote care services, including the Pop-up-Palliative Care Services in North Queensland, has supported distribution to ensure that each remote clinic has received resources designed for First Nations families.
Through extensive collaboration, use of empirical evidence and alignment with best-practice principles, caring@home has also produced clinical tools for health professionals. Post-education survey feedback supports their relevance and value for clinicians. These tools are applicable for guiding care for individuals with progressive conditions likely to result in death within 12 months. They have enhanced the provision of quality end-of-life care and enabled services to support individuals to die at home and for some First Nations peoples to finish up on Country, where cultural, spiritual, and family connections are often strongest. Their focus on personalised, community-based care equips clinicians to respond to changing demographics of the Queensland population and align with contemporary approaches to ageing and care delivery. By implementing proactive planning, and delivering best-practice symptom management, the caring@home tools enable providers to offer quality palliative care that supports choice and empowers patients, carers and families.
The caring@home clinical tools have been distributed widely across Queensland and form an integral part of the palliative education sessions delivered by PallConsult, a Queensland Health service. Specialist palliative care teams also use the resources for clinicians such as the PELP Framework when educating non-specialist services, supporting improved communication and collaboration between primary care and specialist palliative care teams.
Implementation of caring@home resources has been supported through face-to-face and online education across Queensland. Online sessions have provided solutions to the challenges that clinicians face in attending in-person education. Online modules for nurses and GPs are also available and have been divided into concise, self-paced segments, allowing integration into busy clinical schedules.
For the project to succeed, innovative solutions to the challenges that come from living in rural communities were required. Digital solutions included downloadable apps with offline functionality, which ensured access even where internet is unavailable. caring@home has worked with HealthDirect to establish a system whereby clinicians can easily identify local community pharmacies stocking medicines from the Core Palliative Medicines List, supporting timely access to essential medications.
Sector-wide engagement was also critical to success. caring@home has worked closely with other national palliative care projects and implemented a comprehensive communications strategy to support awareness and uptake across the state.
caring@home is currently seeking further funding to sustain and build on this important work, ensuring continued support for community-based end-of-life care across Queensland.
References
1) Swerissen H, Duckett SJ. What can we do to help Australians die the way they want to? Med J Aust. 2015;202(1):10-13. Available from: https://www.mja.com.au/system/files/issues/202_01/swe01580.pdf
2) Australian Government. Aged Care Act 2024. Canberra (ACT): Federal Register of Legislation; 2024. Available from: https://www.legislation.gov.au/C2024A00104/latest/text
3) My Aged Care. Support at Home program. Canberra (ACT): Australian Government; 2025. Available from: https://www.myagedcare.gov.au/aged-care-programs/support-at-home-program
4) Swerissen H, Duckett S. Dying well. Melbourne: Grattan Institute, 2014 https://grattan.edu.au/wp-content/uploads/2014/09/815-dying-well.pdf
5) Wills R, Johnston T. Variation in end-of-life care in Queensland. Brisbane (QLD): Queensland Health; 2012. Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0024/144717/statbite51.pdf
6) Chow J, Jobburn K, Harlum J, Agar M. Economic Evaluation of the Palliative Care Home Support Packages Program. Journal of Service Science and Management. 2022;15:576-600. Available from: https://opus.lib.uts.edu.au/bitstream/10453/166084/2/Economic%20Evaluation%20of%20the%20Palliative%20Care%20Home%20Support%20Packages%20Program.pdf
Key contact
Jane Stephens
Clinical Nurse Consultant
Metro South Health HHS