Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
To enhance shared care in palliative care by strengthening collaboration between general practice teams and specialist services through a nurse practitioner-led model.
Dates: February 2024 - Ongoing
Implementation sites: Princess Alexandra Hospital
Partnerships: Brisbane South Primary Health Network
Aim
To improve access to coordinated, person-centred palliative care that enables more people to receive care and die in their preferred place.
Outcomes
- Improved collaboration between general practitioners (GPs), practice staff, and specialist palliative care services, supporting more coordinated shared care.
- Earlier identification of patients that need advance care planning and specialist palliative care involvement.
- Increased GP engagement and participation in shared care, particularly among practices previously unfamiliar with the model.
- Strengthened GP confidence in managing palliative patients at home and in residential aged care settings.
- Delivery of 37 education and mentoring sessions, four Communities of Practice (CoP) events, and five focused palliative care workshops, engaging over 200 healthcare professionals.
Background
The project Nurse Practitioner-Led Shared Care in Palliative Care: A Collaborative Approach emerged from a growing recognition of the challenges involved in providing coordinated, community-based palliative care. While many people living with life-limiting illness express a preference to receive care, and where possible die, in their own homes, achieving this outcome relies on strong collaboration between primary care providers and specialist palliative care services.
In practice, however, care delivery can sometimes be fragmented. General practitioners (GPs) play a central and trusted role in supporting patients throughout their illness journey, yet opportunities for shared care with specialist palliative services have not always been fully realised. Factors such as limited familiarity with referral pathways, competing clinical demands, and the time required for care coordination can make participation in shared care challenging. As a result, patients may be referred later in their illness trajectory, and opportunities for early conversations around advance care planning and coordinated support may be missed
Methods
In partnership with the local primary health network, this project secured funding to strengthen general practitioner (GP) engagement in shared care of palliative patients. A nurse practitioner (NP) was appointed as the interface between specialist palliative care and primary care. A gap analysis was conducted to identify key areas for improvement. Ten GP practices were initially recruited, with a funding incentive provided to support non-billable time. A community of practice (CoP) was established alongside structured education sessions guided by a steering committee.
Discussion
The success of this project was supported by strong collaboration between specialist palliative care services, the Brisbane South Primary Health Network, and participating general practices. Executive support, funded time for non-billable activities, and the appointment of a nurse practitioner (NP) as a consistent clinical interface created an environment that enabled engagement and strengthened relationships across services.
A key lesson learnt was that building trust and shared understanding between primary and specialist care requires time and ongoing engagement. Flexible delivery of education and mentoring, alongside the Community of Practice, supported clinician confidence and encouraged participation in shared care. The NP role was central in improving communication, navigation of services, and continuity of care.
Limitations included the small number of participating practices, competing clinical demands within general practice, and reliance on time-limited project funding and the lack of an integrated digital platform enabling real-time information sharing between primary care and specialist palliative care providers. Next steps include ongoing evaluation and exploration of sustainable funding models to embed the NP interface role into routine service delivery and support broader adoption of shared palliative care models.
References
Royal Australian College of General Practitioners. (2022). RACGP curriculum and syllabus for Australian general practice. Palliative Care. Retrieved from https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/home
Royal Australian College of General Practitioners. (2023). Shared Care Model between GP and non-GP specialists for complex chronic conditions. Retrieved from RACGP - Shared Care Model for complex chronic conditions
Reymond, L., Parker, G., Gilles, L., & Cooper, K. (2018). Home-based palliative care. Australian Journal of General Practice, 47(11), 747-752. https://doi.org/10.31128/AJGP-06-18-4607
Key contact
Ruth Ikobe
Nurse Practitioner - Project Lead
Metro South Health HHS
Email: ruth.ikobe@health.qld.gov.au