A palliative and end-of-life care model for GPs

Client: South Eastern NSW Primary Health Network (COORDINARE)


South Eastern NSW Primary Health Network (COORDINARE) works with General Practitioners (GPs), other primary healthcare providers, hospitals and residential aged care facilities across South Eastern NSW to improve and better coordinate care for patients.

ZEST worked with COORDINARE to develop a model of care to support integrated and coordinated palliative and end-of-life care in the region.


The model of care aims to:

  • Support more consistent involvement of GPs in palliative and end-of-life care
  • Strengthen the coordination and management of palliative and end-of-life care between GPs, the specialist palliative care service, primary health nurses and other care providers
  • Improve outcomes for patients with palliative needs and their families and carers, including greater support for dying at preferred place of choice.

How the model was developed

This model draws on existing models of care from Australia and internationally. It was refined for the local context through consultation with over 45 key informants, input from a local Expert Advisory Group, and testing and validation with stakeholders from across the region.



A stepped care approach

The model is based on a stepped care approach, which involves matching the needs of the individual to a hierarchy of care and services, from the least to the most intensive. A key component of the model is multidisciplinary care, supporting professionals across service settings to deliver comprehensive care aimed to achieve the best possible outcomes for patients and their carers.


Engagement with over 100 stakeholders across the sector through key informant interviews, two state-wide workshops, and two telephone focus groups with regional and rural participants.

Development of strategic priorities and recommendations to address and improve medication management for people with palliative care needs in NSW.

““ZEST had a collaborative and adaptive approach. To develop the model they combined a rigorous evidence base with strong engagement of experts and other stakeholders. This means the model is both robust and relevant to the diverse service settings across our region””

Linda Livingstone, Director, Engagement and Coordination, COORDINARE