Palliative care and residential in-reach team: finalists in 2026 HESTA Excellence Awards

The model of care has proved so successful it has received permanent funding, and it offers a scalable approach for wider adoption. 

‘The team is now working towards a pitch to the Department of Health and Victorian government to support broader scaling of the model,’ shared Associate Professor Peter Poon, Supportive and Palliative Care Project Lead. 

A gap in care 

The team identified an area of need in aged care, with many older people having limited access to timely and appropriate palliative care.  

Most impacted were aged care residents nearing the end of life, with many transferred to emergency departments during periods of deterioration, despite being frail, confused, or at the end of life. These transfers were distressing for residents and their families, often resulting in care that did not align with the person’s goals or preferences. Families reported uncertainty, poor communication, and a lack of support during an already difficult time.

A streamlined referral pathway was developed for Monash Health’s hospital Residential In-Reach service, and a palliative care clinical nurse consultant was embedded into the service. The role provided aged care facilities with a single, easy point of contact for palliative care advice and support. 

‘The role has bridged a critical gap between hospital and community services, ensuring timely access to palliative care for residents in aged care facilities, and a smooth transition for patients returning there,’ said Dr Adam Mohd Idris, Residential In-Reach Service Director and Geriatrician. 

Making an impact 

Over the 8-month implementation phase of the project, 65% of residents were reviewed within 24 hours of referral. 

Improved outcomes included: 

• reductions in delays 

• simplified communication 

• more coordinated and compassionate care with fewer avoidable hospital presentations 

• and better support in symptom management, education needs and terminal care. 

‘The feedback from families lucky enough to have [the palliative care clinical nurse consultant’s] involvement has been overwhelmingly positive,’ said Dr Anika Kibria, Geriatrician. 

‘[The Palliative Care Clinical Nurse Consultant] also educates our own staff with practical knowledge and guidance around palliative care principles and service logistics,’ said Dr Timothy Bayles, a geriatrician involved in the service. 

The Palliative Care Clinical Nurse Consultant who joined the service team, Esther Wen, notes that the role greatly enhanced the quality of genuine palliative care support within Residential Aged Care Facilities. 

‘This includes more person-centred care, earlier recognition of clinical deterioration and palliative symptoms, reduced unnecessary hospital transfers, and offering meaningful support for both residents and their families,’ said Esther. 

‘The role has strengthened communication between hospitals, Community Palliative Care Services, and general practitioners. It also plays a role in care coordination and building confidence among Residential Aged Care Facility registered nurses.’ 

Partners in the project included: 

• Associate Professor Peter Poon, Project Lead and Principal Investigator, palliative care physician, Supportive and Palliative Care Research Lead 

• Esther Wen, Palliative Care Clinical Nurse Consultant 

• geriatricians and palliative care physicians, Dr Amelia Crabtree, Dr Scott Reeves, Dr Rachel Everitt and Dr Neil Robinson; Residential In-Reach Nurse Unit Manager and her team – Michelle Purtell 

• close collaboration between several Monash Health teams with operational leadership of Helen Richards, Residential In-Reach and Community Services, Dr Adam Mohd Idris, Aged Care and Rehabilitation, Dr Fiona Runacres, Supportive and Palliative Care, and Dr Philip George, Hospital In The Home Services 

• Dr Catriona Parker for research and evaluation expertise encompassed contributions to initial funding application and project design  

• Dr Laura Bird for oversight of outcome measurement, ethics, and dissemination 

• Mika Musgrave-Takeda, Jade Hudson, Isabella Hall, and Emmy Trinh for critical research assistant support with coordination, data management, analysis, and reporting  

• industry and sector partners included Regis Aged Care, who contributed frontline aged–care perspectives and implementation sites; Palliative Care South East, represented by Kelly Rogerson and Dr Patrick Steele, supporting continuity across hospital and community care; South Eastern Melbourne Primary Health Network represented by Campbell Rule 

• project sponsor ARIIA, whose funding enabled the project’s success 

• and lived experience was embedded through close partnership with aged care providers, and front-line staff, during design and implementation, with consumer representatives sitting on the project steering committee.

We wish the team luck at the HESTA Excellence Awards on 6 August where the winners will be announced.