How do providers coordinate with external palliative care teams?
The Support at Home care partner should coordinate the practical and aged care services, while the GP and specialist palliative care team lead complex medical and symptom management. A written plan should make clear who does what, how information is shared and who to contact when the person’s condition changes.
Key points
- Ask for details in writing and compare more than one option where possible.
- Make sure the service can safely meet the person's current and likely future needs.
- Individual eligibility, availability and outcomes can vary.
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01Guide sectionHow do Support at Home providers coordinate with external palliative care teams?
Support at Home providers should work alongside external palliative care services rather than trying to replace them.
State and territory palliative care teams commonly manage specialist clinical needs such as symptom control, pain relief, prescribing and medical escalation. Support at Home can add nursing, personal care, respite, meals and practical assistance that helps the person remain at home.
The Support at Home End-of-Life Pathway is specifically designed to complement existing palliative care services.
02Guide sectionWhat does the care partner do?
The Support at Home provider should allocate a care partner who coordinates the person’s aged care services.
The care partner should:
identify the external clinicians and services involved
obtain the person’s consent to share relevant information
develop the care plan with the person and family
clarify which organisation is responsible for each part of care
organise Support at Home workers and services
communicate changes to the relevant clinical team
arrange reviews when the person’s needs change
help prevent duplicated, missed or conflicting services.
Care management is mandatory for Support at Home participants, and dedicated care partners are responsible for planning and reviewing care and services.
03Guide sectionWho may be involved?
The coordinated team may include:
the Support at Home care partner
the person’s GP
community palliative care nurses
a specialist palliative care doctor
Support at Home nurses and personal-care workers
pharmacists
allied health professionals
hospital outreach or discharge teams
family members and unpaid carers
spiritual, cultural or counselling supports.
One organisation may not provide every part of the care. The important point is that responsibilities are documented and understood.
04Guide sectionHow should responsibilities be divided?
A written care plan should identify who is responsible for areas such as:
Specialist symptom management
Usually led by the GP or specialist palliative care team. This may include prescribing medication and managing pain, nausea, breathlessness, agitation or other complex symptoms.
Routine nursing
Support at Home nurses may provide approved nursing services such as wound care, medication support, monitoring and communication with the clinical team.
Personal and practical care
Support at Home may arrange showering, dressing, toileting, meals, domestic help, transport and respite.
Medication supply and changes
The prescribing clinician and pharmacist manage prescriptions and medication changes. Support workers should follow the authorised medication plan rather than making clinical decisions themselves.
After-hours escalation
The plan should state who the family or workers call if symptoms worsen overnight or on weekends.
Emergency care
The plan should explain when to call the palliative care service, GP, ambulance or 000.
Palliative care is commonly delivered by a multidisciplinary team and can be accessed through referral from a GP, specialist or other health professional.
05Guide sectionHow is information shared?
With the person’s consent, the provider should share relevant information such as:
the current care plan
medications and allergies
advance care planning documents
known symptoms and risks
mobility and personal-care needs
emergency contacts
recent changes in condition
worker observations
preferred place of care and treatment wishes.
Support workers should know what changes they must report, including:
increasing pain
breathlessness
difficulty swallowing
reduced eating or drinking
new confusion or agitation
falls
medication problems
reduced consciousness
signs that the person may be approaching death.
The provider should have a clear process for reporting these observations promptly to the care partner and clinical team.
06Guide sectionWhat should happen when the person’s condition changes?
The provider should not wait for the next routine review.
The care partner should:
contact the appropriate palliative care clinician or GP
review whether scheduled services remain suitable
increase or adjust available support where possible
update workers and family members
request an urgent Support Plan Review where additional approval or funding is needed
confirm the after-hours and emergency plan.
For someone who meets the criteria, the provider can help request urgent assessment for the End-of-Life Pathway. Once approved, the provider develops the care plan and coordinates the funded services.
07Guide sectionDoes the Support at Home provider manage all clinical care?
Not necessarily.
A Support at Home provider may employ nurses, but it may not have specialist palliative care doctors, prescribing authority or an after-hours clinical service.
Families should not assume that choosing a provider offering nursing means it can independently manage:
complex pain or symptom crises
rapid medication changes
continuous clinical monitoring
24-hour nursing
emergency medical treatment.
The provider should be honest about its capabilities and have established referral and escalation processes.
08Guide sectionWhat should happen after a hospital discharge?
Before discharge, the provider should communicate with the hospital and palliative care team about:
the expected discharge date
current medications
equipment required at home
symptom-management instructions
personal-care needs
mobility and transfer risks
follow-up appointments
who will visit first
who to contact if the person deteriorates.
Services should be scheduled before the person arrives home where possible. A discharge should not rely on the family discovering after arrival that nursing, equipment or medication has not been arranged.
09Guide sectionWhat should families ask the provider?
Ask:
Who will be our main coordination contact?
Do you regularly work with community palliative care teams?
Which clinical services can you provide directly?
Which services must come from the health system?
How will you communicate with the GP and palliative care nurses?
Who can workers contact after hours?
What happens if pain or symptoms suddenly worsen?
How are medication changes communicated to workers?
Can you provide additional personal care or respite quickly?
How will you coordinate equipment and supplies?
Will all workers have access to the current care plan?
What happens if the person’s needs exceed your workforce or clinical capacity?
Who supports the family immediately before and after death?
10Guide sectionWarning signs
Be cautious if a provider:
says it can manage everything without involving the GP or palliative care team
cannot explain who provides after-hours clinical advice
has no process for sharing updates with external clinicians
relies on family members to pass every message between services
sends workers who have not read the current care plan
cannot respond when symptoms or care needs change
confuses routine aged care nursing with specialist palliative care
cannot explain what happens when the person dies at home.
11Guide sectionWhat should I do next?
Confirm the details with My Aged Care or the relevant provider, write down your questions and ask for important information in writing before making a decision.
12Guide sectionHelpful Local Home Help resources
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