Support Systems - Home Care

Support Systems

Providing palliative care and advance care planning for clients and their families requires a coordinated approach outlined under the following five actions. The first action to take is to establish a palliative care and an advance care planning working group.

The purpose of the working group is to support palliative care and advance care planning through:

  1. Establishment of governance structures for implementation
  2. Identification and support of champions
  3. Development and review of policies and procedures
  4. Review of clinical domains
  5. Review or development of a staff training strategy
  6. Engagement and monitoring quality improvement activities
  7. Review of aged care standards and funding support
  8. Identification and engagement of key internal and external stakeholders

Who might be invited/involved to the working group?

  • A client and/or family representative
  • Care director or care manager
  • Registered nurse/enrolled nurse
  • Careworker
  • Allied health representative
  • Pastoral or spiritual care representative
  • GP
  • Primary Healthcare Network (PHN) representative
  • Specialist palliative care representative
  • Pharmacist

The number of people engaged in the working group will depend on the size of the organisation. The working group should meet at least monthly, develop a standard agenda and meeting minutes with action items that are recorded. If your service is part of a larger organisation then coordination between working groups on organisational-wide issues, such as policies and procedures, is recommended. Also consider benchmarking between services in a larger organisation by utilising the audits provided in the Quality Improvement section of this toolkit.

Terms of reference should be developed that indicate working group membership, term of membership, frequency of meetings, selection of a Chair, and reporting requirements within the organisation. Actions from meetings should be recorded for each meeting and these should be circulated at least one week prior to the next meeting.

The role of the palliative care and advance care planning champions may be to:

  • Act as an ambassador for palliative care and advance care planning
  • Romote and review how palliative care and advance care planning is being provided
  • Selected champions participate in the working group
  • Act as a resource for other staff, clients and family
  • Assist with or coordinate palliative care and advance care planning quality improvement activities.


Local champions should be identified that can support the organisation working group. Champions may be any staff member within the organisation and can be grouped by clinical champions who have a direct clinical role (e.g. registered nurses, enrolled nurses, careworkers, allied health and pastoral care) and non-clinical champions (e.g. kitchen staff and volunteers).

How many?

The number of champions needed is up to the working group and will depend on the geographical structure of the organisation, model of care, and profile of clients. While there is no specific number required, it is recommended to have enough champions to ensure coverage across shifts, weekdays, weekends and holidays.

The working group members and champions in the organisation can be acknowledged by displaying photos and names on a notice board, which can be viewed by clients, families, GPs or external providers.

The working group should meet with the executive and policy person/section of the organisation to review policies and procedures to support palliative care and advance care planning. Within a larger organisation it is critical that the organisation-wide policies and procedures are agreed upon and are followed by the working groups. A policy set the principles for the direction of the organisation and a procedure should be a series of steps that are completed to support the policy. Areas where a policy and/or procedure may be useful include:

  • Advance care planning
  • Palliative care
  • Verification of death
  • Nutrition or hydration
  • Administration of subcutaneous fluids
  • Administration of subcutaneous medications: Intermittent and via a syringe driver
  • Subcutaneous Needle Insertion and Management
  • Care in the last days of life
  • Care of the body after death
  • Care of the family during and after the death of a loved one
  • Care of colleagues
  • Care of self
Policies and procedures should be linked to evidence and accreditation standards. palliAGED provides the latest evidence on palliative care and advance care planning for older people. Specific topics should be reviewed to inform the development of policies and procedures and these should be linked to the Aged Care Quality Standards provided by the Aged Care Quality and Safety Commission.

The ELDAC 'Clinical Care' section of this toolkit identifies eight domains of clinical care. As part of this clinical action, the working group with assistance from champions, should review existing clinical forms, tools, and care management practices against these clinical domains. An update plan should be identified if revisions are required, or tools or processes are deemed inappropriate. This action should be completed regardless of the type of system your organisation utilises (e.g. electronic, hard copy, or a combination of both). The Quality Improvement section of this toolkit provides the interactive ELDAC Advance Care Planning and Palliative Care Organisational Audit that can assist with achieving this action.

If updates to forms, tools, or care practices are required, the working group should discuss the timeframes to achieve these revisions and how these will be introduced and communicated to staff, clients and families.

To create and foster a culture of learning about palliative care and advance care planning, an organisational training strategy is needed. The ELDAC Personal Learning section of this toolkit provides opportunity for individual staff to identify their personal learning needs and set a learning plan. This section of the toolkit also links to online and other educational training opportunities. In contrast, this action is focused on the development of an organisation-wide staff education and training strategy.

Some key points for the working group to consider are:

  • Is there a core set of educational units/competencies in palliative care and advance care planning that are expected of all staff?
  • What support do staff have to participate in education and training on palliative care and advance care planning within the organisation?
  • What support do staff have to participate in education and training on palliative care and advance care planning external to the organisation?
  • How are external providers engaged in delivery of education and expertise sought?
  • Is education/information on palliative care and palliative care provided to clients and families?
  • Are clinical staff trained in searching and appraising new evidence to support palliative care and advance care planning?

Page updated 15 February 2023