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PCOC in Primary Care

Clinicians and health professionals

Overview for clinicians

PCOC in Primary Care supports general practices to recognise palliative care needs earlier, using structured, practice-ready approaches that integrate into routine workflows.

Through GenPal, GPs and practice teams are supported to review patient-reported outcomes over time, inform clinical judgement, and have proactive conversations about care planning, symptom management, and referral when appropriate.

GenPal responds to consistent evidence that many people living with serious, life-limiting illness are identified late and enter specialist palliative care close to the end of life. This is particularly common for people with non-cancer conditions and for those primarily cared for in the community. GenPal aims to support earlier recognition of changing needs and timelier, coordinated responses within general practice.

GenPal in practice: a case vignette

Earlier recognition, better coordination

Mrs K is a 72-year-old woman living with chronic heart failure and chronic kidney disease. She attends her general practice regularly but has never been referred to specialist palliative care. Although she experiences increasing fatigue and shortness of breath, these changes have been managed reactively during brief consultations.

Through NPCC, the practice implements GenPal.

Mrs K is identified through a routine search and invited to participate. Over several weeks, her patient-reported assessments show worsening fatigue, reduced function, and increasing time spent resting at home.

Reviewing these results before her appointment, the GP recognises a pattern of decline that had not been fully apparent during consultations alone. This prompts an earlier, proactive conversation with Mrs K and her family about goals of care, symptom management, and support needs.

The GP adjusts her management plan and initiates a timely referral to community-based specialist palliative care. As a result, Mrs K receives coordinated support earlier in her illness, avoids an unplanned hospital admission, and feels better supported at home.

GenPal - A Screening Tool for General Practice (Version 2)

Early identification of palliative care needs in general practice for GPs, Practice Nurses and Primary Health Networks.

Head to PCOC's YouTube channel to watch the GenPal video for General Practice

 Introducing GenPal, a screening and decision support tool for general practice. It helps GPs in the timely identification of patients with potential palliative care needs  by using indicators and patient reported outcome measures.  Cyclic GenPal screening begins in the general practice chronic condition clinic. GenPal is easy to implement. Once set up, it runs mostly in the background, creating ongoing efficiencies for the practice.

Step one: identify patients. Each month, general practice administration runs a preset search to identify patients who are aged 45 or more, diagnosed with at least one of the top five causes of expected death in Australia, and frequency of practice visits is on average once every three weeks.  For those who meet these criteria, the GP then applies the surprise question.

Step two: GP review. Each GP reviews their patients on the list and applies the surprise question – “would I be surprised if this patient died in the next 12 months”?  Patients for whom the answer is yes, those names are removed from the list. Those patients remaining on the list are then invited to participate in regular screening with GenPal.

Step three: start screening. At the first appointment, the benefits of participating in the screening process are explained to the patient.  Consent is obtained and patients are shown how to complete the screening on their phone using the Edmonton Symptom Assessment System. Patients submit screening results in the waiting room. Just prior to seeing the nurse or GP for a review, the patient will be asked to respond to two questions and rate 11 symptoms on a scale from zero to 10 based on the symptom severity over the past 24 hours.  Patients also submit screening results at home in between reviews at the practice. This means that the patient screening occurs every three weeks.

Step four: respond to results. Patients receive tailored symptom resources from healthdirect and other trusted sources. These resources are based on the severity of  needs.  High scores trigger repeat screenings. The patient may opt out later in the process. The practice receives a notification email with the subject line summarizing the screening results with concerning scores highlighted. The general practice responds according to their clinical pathway. Results are saved directly into the patient's record.

 Step five: consider referral. If symptoms are problematic, the patient has reduced functioning and a recent unplanned hospitalisation, the GP may consider referral to specialist palliative care using their clinical judgment.

The patient then receives shared care from both the GP and specialist palliative care service.

For detailed information on GenPal, please visit the NPCC website.

GenPal

GenPal is a structured palliative care needs assessment and decision-support process developed through the NPCC to support earlier identification of palliative care needs in general practice.

GenPal was designed in response to consistent evidence that many people living with serious, life-limiting illness are identified late and enter specialist palliative care close to the end of life. This is particularly the case for people with non-cancer conditions and those cared for primarily in the community.

GenPal aims to support general practice teams to recognise changing needs earlier and to respond in a timely, coordinated way.

Simple and Intuitive

  • Quick and easy to use, no training required
  • Self-evident for GPs at any experience level
  • Completed in patient time, not GP clinical time
  • Pre-identification of issues supports more focused and efficient consultations
  • Integrates into existing practice software
  • One-click access to latest results in the medical record
  • Flags only concerning results, avoiding alert fatigue

Clinically Meaningful

  • Integrates structured, patient-reported data into clinical decision-making
  • Covers all conditions and at all stages, with built-in referral prompts for timely escalation
  • Adds value to GP clinical judgement, does not replace it
  • Derived from validated measures and evidence-based , supporting acceptability and confidence
  • Supports frequent patient reflection on symptoms and functional changes, priming patients for goals-of-care conversations
  • Supports structured reviews / consultations, supports proactive care planning and crisis avoidance
  • Standardised PDFs of GenPal results can be attached to specialist palliative care referrals, using consistent and standardised palliative care terminology to improve referral confidence and SPC triage and referral acceptance

Fits Real-World Practice

  • Aligns with and supports a standard 15-minute consultation / nurse review
    Anticipated to reduce urgent on the day or unplanned appointments
  • Secure, with low administrative burden
  • Clarifies review / appointment purpose, supporting reduction in fail-to-attend (FTA) rates
  • Funded through MBS, at no additional cost to practice or patient
  • Financially sustainable across all practice sizes and business models
  • Contributes to practice accreditation evidence and GP CPD points

Supports Patient Engagement

  • Enhances patient engagement and shared understanding of care needs
  • Clarifies review / appointment purpose for the patient, supporting reduction in fail-to-attend (FTA) rates
  • Patient more likely to receive the care aligned with their values 

GenPal is not a diagnostic tool and does not prescribe clinical actions. Instead, it functions as a decision-support aid that complements clinical judgement and supports structured, ongoing assessment of patient needs.

GenPal:

  • Supports GPs and practice teams to identify patients who may benefit from a palliative approach to care
  • Uses patient-reported outcomes to highlight changes in symptoms and function over time
  • Encourages shared decision-making with patients and carers
  • Supports appropriate escalation of care, including consideration of specialist palliative care referral when needed.

This structured approach supports earlier recognition of unmet needs and facilitates proactive conversations about care planning, symptom management, and referral where appropriate.

  • Earlier recognition of changing patient needs
  • Support for clinical decision-making, not automation
  • Improved coordination with specialist palliative care services
  • A patient-centred, team-based approach to care

GenPal is embedded within routine general practice workflows and is designed to minimise additional burden on clinicians.

The process involves:

  • Identifying patients living with serious, life-limiting illness who attend the practice regularly
  • GP clinical review using established indicators to determine suitability for participation
  • Ongoing patient self-assessment at regular intervals using validated symptom and functional measures
  • Review of patient-reported outcomes by the practice team prior to consultations.
     

Lack of time in general practice – by far the biggest barrier

  • Recognising the slow, cumulative decline, by both patients and clinicians and detecting changes in needs
  • Uncertainty in prognosis for chronic conditions. When to have discussions? When to refer?
  • Limited awareness of what palliative care offers is incorrectly associated with end of life or giving up.
  • Fear of causing distress or losing hope.

GenPal places patients and carers at the centre of the assessment process. By capturing patient-reported outcomes over time, it enables clinicians to better understand symptom burden, functional decline, and changes in wellbeing that may not be evident during brief consultations.

By standardising how needs are identified and reviewed in primary care, GenPal supports more consistent, needs-based approaches to escalation and referral. This improves the quality of information available at referral and strengthens coordination between general practice, Primary Health Networks, and specialist palliative care services.

GenPal is currently being implemented and evaluated in selected general practices across Australia. Evidence from this work will inform future strategies for sustainable, scalable integration of palliative care needs assessment within general practice at a national level.

Primary Health Care Resources