PCOC in Primary Care

The PCOC in Primary Care project supports earlier identification and improved coordination of palliative care needs in Australian general practice.

The project strengthens the role of primary care in recognising changing patient needs and supporting timely, needs-based escalation of care across the illness trajectory.

At the centre of the project is GenPal, a structured decision-support process that complements clinical judgement. GenPal supports consistent needs assessment, captures patient-reported outcomes over time, and improves coordination and information transfer between general practice, specialist palliative care, and other care settings.

GenPal, a tool that helps doctors notice your changing needs, lets doctors look at how your health changes over time. This helps your doctor:

• plan your care
• take care of your health signs
• refer you to palliative care services when needed

The project has been developed from the strong foundations of the Palliative Care Outcomes Collaboration (PCOC), Australia’s internationally recognised program for measuring and improving palliative care outcomes. PCOC has a long history of supporting quality improvement in specialist palliative care services through consistent outcomes measurement, benchmarking and feedback. Building on this success, PCOC in Primary Care is a strategically significant expansion that recognises the critical role general practice plays in caring for people with life-limiting illness. 

PCOC in Primary Care extends PCOC’s established outcomes and benchmarking framework into general practice, supporting:

• Earlier identification of palliative care needs
• Structured, practice-ready assessment processes
• Improved coordination between general practice and specialist palliative care services
• A more proactive and planned approach to palliative care, closer to home

This work strengthens palliative care across the whole health system by supporting GPs to identify needs early, respond consistently, and escalate care appropriately when specialist input is required.

Many people with a life-limiting illness could benefit from a palliative care approach earlier, yet their needs are often identified too late. The project supports general practices to recognise palliative care needs sooner, have meaningful conversations, and provide proactive, person-centred care—helping people receive the right care, at the right time, closer to home.

While many patients can have their palliative care needs well managed in general practice without specialist services, timely identification of those needs remains essential to ensure appropriate support and escalation when required.

Currently, referrals to specialist palliative care are often late and crisis-driven:

• The majority of specialist palliative care referrals originate in acute settings rather than primary care, with 70% of specialist palliative care referrals originating during a hospital admission
• Only 8% come directly from general practice nationally and this has not changed over the last several years
• GP-initiated referrals generally occur late, with a median of 17.5 days of specialist care before death
• Most expected deaths in Australia are from non-cancer conditions but approximately only  35% of specialist palliative care recipients have non-cancer diagnoses
• People with non-cancer conditions experience inequitable access to specialist palliative care, despite comparable symptom burden

Despite the central role of general practice in caring for people with life-limiting illness, palliative care needs are frequently identified late. This limits opportunities for early symptom management, advance care planning, carer support and coordinated care.

General practices face a combination of clinical, systemic and interpersonal challenges, including prognostic uncertainty, time pressures, fragmented referral pathways and the difficulty of initiating conversations about goals of care. Patients and carers also report uncertainty about what palliative care involves, when it may be beneficial, and how to access appropriate services. 

Importantly, not all patients with a life-limiting illness require specialist palliative care. Many would benefit from an earlier, structured palliative care approach delivered within general practice, with timely escalation when complexity increases.

The project addresses these gaps by supporting earlier identification of palliative care needs in primary care, strengthening care planning and coordination, and improving integration between general practice, PHNs and specialist palliative care services. This enables more timely, equitable and person-centred care across the illness trajectory.

PCOC in Primary Care aligns closely with Australian Government priorities, including:

• Improving access to palliative care in the community;
• Reducing avoidable hospital admissions and emergency presentations;
• Addressing inequities in access for non-cancer populations and culturally diverse communities;
• Strengthening primary care and integrated models of care.

The project’s emphasis on early identification, patient-centred care, and system coordination directly supports national palliative care strategies and broader primary care reform agendas.

The project aims to:

• Develop a refined needs assessment and decision aid process, with recommendations for national rollout.
• Improve early identification of palliative care needs in primary care settings.
• Identify key personal, interpersonal, and system supports for administering clinical protocols.
• Provide evidence on optimal timing for initiating palliative care and referring to specialist palliative care, using patient-reported outcomes and tracking changes in care pathways.

• Improved equity in access to palliative care for patients with non-malignant chronic conditions
• Improved outcomes for patients, families and carers
• Increase referrals from GPs to community palliative care services, helping patients stay at home for longer