National Palliative Care Coordination project

NPCC Logo

 

 

To enquire about the NPCC project, please email NPCC-contact@uow.edu.au or contact Project Manager, Stacey Heer on sheer@uow.edu.au.

GenPal Video, version 1, for HCPs

Early identification of palliative care needs in general practice, version 1 for GPs, Practice Nurses and Primary Health Networks. NPCC is the National Palliative Care Coordination project and is funded by the Australian Government Department of Health, Disability and Ageing.

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

Introducing GenPal. A screening and decision support tool for general practice. It helps GPs identify patients with potential palliative care needs early 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 1: 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 3 weeks. For those who meet this criteria, the GP then applies the surprise question.

Step 2: 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 3: Start screening

At the first appointment, the benefits of participating in the screening process is 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 0-10 based on the symptoms severity. Questions can be skipped if not relevant.

Patients also submit screening results at home, in between reviews at the practice. This means that the patient screening occurs every 3 weeks.

Step 4: Respond to results

Patients receive tailored symptom resources. These resources are based on their needs. High scores trigger follow-up resources and a repeat screening in 24 hours. The practice receives a notification email, with the subject line summarising the screening results, with concerning results highlighted.

The general practice responds according to their clinical pathway. Results are saved directly into the patient’s record.

Step 5: 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 judgement.

The National Palliative Care Coordination (NPCC) project aims to enhance the capacity and capability of general practice in identifying palliative care needs and ensuring timely, needs-based referrals to specialist palliative care services.

Funded by the Australian Government, Department of Health, Disability and Ageing, this initiative seeks to address gaps in palliative care access, particularly for individuals with life-limiting illnesses beyond cancer.

NPCC project GenPal snapshot October 2025

Currently, a significant proportion of specialist palliative care referrals (≈70%) originate from acute hospitals, with only 7% initiated by GPs. This results in unmet care needs, increased hospitalisations, and limited access for non-cancer patients requiring palliative care support.

The NPCC project addresses this by developing GenPal, a structured palliative care needs assessment and decision support tool, to identify patients who may benefit from early palliative care.

Watch the GenPal video, version 1, for HCPs

  • Develop and refine a needs assessment and decision support 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 this protocol.
  • Provide evidence on optimisal timing for initiating palliative care and referring to specialist palliative care using patient-reported outcomes and tracking changes in care pathways.

The NPCC project team

Sabina Clapham is a healthcare clinician and leader specialising in palliative care outcomes, quality improvement, and education. As Director of the Palliative Care Outcomes Collaboration (PCOC) and Coordinating Investigator for the National Palliative Care Coordination (NPCC) Project, she has led the national implementation of patient outcome measures, enhancing the quality, sustainability and impact of palliative care services across Australia.

Currently pursuing a PhD at the University of Wollongong, Sabina’s research focuses on defining health service capabilities in palliative care. Her work has attracted $12.5 million in research funding, with outputs including eight peer-reviewed publications, over 1,000 non-traditional outputs, seven conference presentations, and six keynote addresses across five countries. Sabina’s outcome measurement protocols are implemented in more than 200 Australian palliative care services, benefiting 65,000 patients annually. 

P: (02) 4239 2372
E: sabinac@uow.edu.au

Professor Judy Mullan (PhD, GAICD, FSHPA, BA, BPharm) is a nationally and internationally recognised leader in health services research, with a career spanning over three decades in pharmacy, academia, and translational health research. At the University of Wollongong (UOW) her leadership roles include Associate Head of School, Graduate School of Medicine ( since 2020) and Deputy Director for the new Heath Innovations Research Entity (>200 research members; since 2023). Her research focuses on the quality use of medicines, chronic disease management, health literacy, and patient education—areas in which she has made significant contributions through over 135 peer-reviewed publications and more than 150 national and international conference presentations.

Professor Andrew Bonney has over 30 years of experience as a general practitioner on the South Coast of NSW. He is Roberta Williams Chair of General Practice and Associate Head of School Research Strategy in the Graduate School of Medicine at the University of Wollongong. Andrew's goal is to foster quality, equity and sustainability in primary care through education and research, with a focus on regional and rural Australia.

As an occupational therapist with 25 years clinical experience, Deidre has an in depth understanding of the public health system and the value and importance of clinical research that informs practical patient care. Her clinical and research focus is in palliative care and she has a particular interest in ways to optimise function at the end of life. Deidre's research interests focus on factors that optimise function for people with advanced disease and ways to measure meaningful clinical gains in this area. Deidre examines this from patient, caregiver, and health professional perspectives to obtain a broad understanding of the clinical issues.

Dr. Poudel holds a PhD in Pharmacy from the University of Queensland (UQ) and has over 15 years of experience in pharmacy education, research, and practice across Nepal, Canada, and Australia. A recognized expert in aging, pharmacotherapy for frail older adults, and palliative care, he specializes in developing research-driven learning environments that foster academic excellence and innovation

His research has influenced policy changes and earned academic recognition. Beyond academia, he has served on university committees, engaged in community outreach programs, and reviewed for leading journals and funding bodies.  He has also supervised PhD and Master's candidates in both academic and industrial settings at multiple institutions and levels of responsibility.

P: (02) 4239 2146
E: apoudel@uow.edu.au

Animut received his PhD in Public Health from the University of Technology Sydney in 2023 and joined the NPCC project at the University of Wollongong in 2024. Before joining this role, Animut gained significant experience as a casual academic and research assistant in the School of Public Health at UTS. Additionally, he served as a full-time lecturer at Debre Markos University in Ethiopia. Animut has a profound interest in employing advanced statistical analysis across various health domains, including palliative care, infectious diseases, child malnutrition, chronic diseases, neonatal health, and maternal health.

P: (02) 4239 2026
E: aayalew@uow.edu.au

Stacey has qualifications in psychology and palliative care. She has worked previously in a regional palliative care team as the psychosocial support coordinator and various community health roles. More recently Stacey was the Healthy Ageing and Palliative Care Manager with Murrumbidgee Primary Health Network, where she developed a PCOC model of care for general practice, in collaboration with the PCOC team. Stacey joined the PCOC team as the National Education Lead in 2023 and is also undertaking the role of Project Manager for the National Palliative Care Coordination (NPCC) project. Stacey is particularly interested in improving access to timely, quality palliative care for all Australians.

P: (02) 4239 4632
E: sheer@uow.edu.au

Dr Jack Thepsourinthone joined the team as a Research Specialist in 2025 and holds a PhD in Health Science, a Master of Research, and a Bachelor of Psychology. They have extensive expertise in designing, conducting, and analysing research within the public health sector, examining various social determinants of health among minority and marginalised populations (e.g., LGBTQIA+, POC, ageing). Their academic outputs include numerous peer-reviewed publications and conference presentations, and explore topics including mental health, quality of life, and access to health services.

P: 02 4239 3723
E: jackth@uow.edu.au 

Keryn joined the NPCC project in February 2025 and has a background in Physiotherapy, working throughout the Illawarra and Sydney Health Districts through 1983-2000, mainly in neurological rehabilitation. She completed a Master of Public Health (2005) and PhD (2010) at UOW and has worked on a casual or part-time basis as a researcher at UOW since 2006, as well as working as a Physiotherapist in Aged Care (2016-2019). She has managed or been a co-investigator in a wide range of mixed method research projects over the past 16 years, as well as extensive teaching expertise through working for the Faculty of Health and Behavioural Sciences/Faculty of Social Sciences at the University of Wollongong. She is interested in the use of mixed method research methodologies, particularly in evaluation, and working with vulnerable populations to improve health and wellbeing.

P: (02) 4221 5214
E: kerynj@uow.edu.au

Linda joined AHOC at UOW in 2009 after extensive experience working in aged and community care program management in both the Commonwealth Government and community sectors. In AHOC, Linda has provided administrative and project support to the Palliative Care Outcomes Collaboration (PCOC), the Centre for Health Research Illawarra Shoalhaven Population (CHRISP) and the electronic Persistent Pain Outcomes Collaboration (ePPOC). Linda joined the National Palliative Care Coordination (NPCC) project in November 2024.

P: (02) 4221 5092
E: lindaf@uow.edu.au

National Palliative Care Coordination Project (in progress). University of Wollongong, NSW, Australia. Funded by the Department of Health, Disability and Ageing (2023-2027).