Celebrating our 2026 HESTA Excellence Award winners

Associate Professor Peter Poon, Supportive and Palliative Care Project Lead said, ‘this award recognises the teams’ innovation, close cross-service collaboration, and measurable system-level outcomes, and above all the daily commitment and dedication of our frontline staff. The work helps ensure that frail older people can receive care that genuinely aligns with their preferences and dignity at the end of life.’

This new model of care has proven so successful it has secured permanent funding and offers a scalable approach with the potential 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.

Responding to a gap in care

The team identified that many older people in residential aged care have 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.

To improve the experience for residents and their families, the team developed a streamlined referral pathway through Monash Health’s Residential In-Reach service and embedded a Palliative Care Clinical Nurse Consultant within the service. This dedicated role gives aged care facilities a single, easy point of contact for specialist 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 a meaningful impact

Over the 8-month implementation phase, 65% of residents were reviewed within 24 hours of referral, with 317 clinical interactions delivered to 172 individual residents across 76 facilities. Subsequently, audit data has demonstrated sustained, exceptional clinical responsiveness and high service adoption in a frail, clinically complex cohort.

The model has delivered improved outcomes, with:

• faster access to specialist support
• simpler communication
• more coordinated and compassionate care, with fewer avoidable hospital presentations
• and stronger support for symptom management, education and terminal care.

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

‘The role also builds capability among our own staff by providing practical education and guidance around palliative care principles and service logistics,’ said Dr Timothy Bayles, a geriatrician involved in the service.

Esther Wen, the Palliative Care Clinical Nurse Consultant who joined the service team, notes that the role greatly strengthened 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.’

A truly collaborative achievement

This award recognises a remarkable collaboration, bringing together specialists from multidisciplinary teams whose expertise contributed to the project’s success.

Dux Balendran, Operations Director, Care in the Home and Community, offered his congratulations to the team.

‘Congratulations to all those involved. This team has shown what’s possible when multidisciplinary expertise is embedded directly into aged care. There are better outcomes for residents, fewer avoidable hospital transfers, and a model we can build on. This is a well-deserved recognition.’

Partners in the project Monash Health Supportive & Palliative Care and Residential InReach teams, Palliative Care South East, Southern Eastern Melbourne Primary Health Network as well as residential aged care provider Regis Aged Care and consumer representatives comprising a key part of the project steering committee.

A huge congratulations to the team on this outstanding achievement and well-deserved recognition at the HESTA Excellence Awards.