South Western Sydney PHN is a not-for-profit health organisation dedicated to supporting general practitioners, practice nurses and other primary health providers.
The Department of Health, Disability and Ageing (DHDA) has developed a resource called the End-of-Life Pathway in response to requests for guidance by GPs on patient eligibility and referrals.
The End-of-Life Pathway is offered for a short term under the Support at Home program. It allows older people who have been diagnosed with three months or less to live to receive funded care services while remaining at home.
The End-of-Life Pathway is designed to complement services received through states and territories, including palliative care.
Support at Home is a program to help older people remain at home as they age. It improves access to services, products, equipment and home modifications to help older people to remain healthy, active and socially connected to their community.
Services can include nursing care, occupational therapy, podiatry, help with personal care, transport and respite care. It also includes services which support culturally safe care, such as access to Aboriginal and Torres Strait Islander health practitioners and health workers.
The DHDA has released a new Support at Home video which is now available on the My Aged Care website. It is targeted at older people and designed to help GPs talk to their patients about short-term pathways. It is available in a variety of languages.
Download GP resources and referral guidance for the End-of-Life Pathway
End-of-Life Pathway GP resource
This resource provides guidance for GPs and nurse practitioners on patient eligibility, referral pathways and how to complete and submit the End-of-Life Pathway form. It also includes information about AKPS scoring, care coordination and available in-home support services for eligible patients.
Support at Home GP resource
This resource provides an overview of the Support at Home program, including available services, short-term pathways and referral options. It also outlines urgent referral processes, reassessment pathways and support available to help older people remain living safely at home.
This article appeared in Practice Pulse on Wednesday, 27 May 2026. If you are a GP, practice nurse or practice manager in South Western Sydney and do not get the weekly Practice Pulse email, speak to your Practice Support Officer.
Healthdirect’s National Health Services Directory (NHSD) now enables pharmacies to include a service offering of ‘Palliative care medicine’ in their listing. The NHSD powers the Service Finder, the public-facing interface of the directory, where the community can find up-to-date information about health services near them. Service Finder is accessed over one million times a month.
Including ‘Palliative care medicine’ as an offering enables health professionals, patients and carers to identify local pharmacies that stock the four medicines from the caring@home National CoreCommunity Palliative Care Medicines List.
caring@home Director, Professor Liz Reymond, says updating pharmacy listings on the NHSD is an important step to ensure local health professionals and families know where to source medicines, without having to drive around or call several places when the need is urgent.
‘‘Stocking medicines from the list plays a vital role in supporting timely medicine access, which can help avoid unnecessary suffering and unwanted transfers to inpatient facilities for a home-based patient,” she said.
“Pharmacies should consider stocking medicines from the list. Always having these four medicines in stock and reflecting that information on Service Finder will enable easier navigation, rapid dispensing and timely access for patients in their community.”
caring@home is a National Palliative Care Project funded by the Australian Government and is led by the Brisbane South Palliative Care Collaborative.
In 2024, caring@home released the National Core Community Palliative Care Medicines List, which identifies four medicines for use by home-based palliative patients who require urgent symptom relief. These four medicines can be used to manage most common end-of-life symptoms.
To find out more and update your listing to include ‘Palliative care medicine’ visit: caring@home
29 August 2025
Attendees praised our Dying to Know Day Expo at the Fairfield Youth and Community Centre on 8 August, with 100 per cent of those surveyed saying they now feel ‘confident in making end-of-life plans and having conversations about death and dying’.
SWSPHN partnered with organisations, including South Western Sydney LHD and Fairfield City Council, to organise the free expo.
The event attracted 280 attendees, primarily from the Fairfield and Canterbury-Bankstown LGAs, 42 volunteers and 37 stalls, including SWSPHN’s stall which attracted 73 visitors, and provided valuable information and resources on advance care planning and the importance of making your healthcare preferences known.
Other stalls included the NSW Trustee and Guardian, Lifeline, Palliative Care NSW, NSW Multicultural Services and Ashes to Ashes.
Attendees had the opportunity to speak to stallholders, join eight information sessions on various end-of-life topics, enjoy light refreshments, and take home free information and showbags. In addition to information sessions in English, we also held sessions in Chinese, Vietnamese and Arabic for the first time.
Ninety per cent of attendees who were surveyed said they would attend another Dying to Know Day Expo in the future. In their feedback, they talked about how they benefited from the conversations with stallholders, and appreciated being able to speak to some stallholders in Vietnamese.
One hundred per cent of attendees who were surveyed now feel confident in making end-of-life plans and having conversations about death and dying. In their feedback, they said it was good to have solicitors and clinicians talking about planning for the future, they ‘learnt something from every session’ and it was good to have a session in Chinese.
Other feedback included: ‘We hope you will make this a permanent fixture, it is definitely a topic people feel the need to know more about, especially those from cultures not as familiar with the traditional Western ways of dealing with death and dying’.
Dying to Know Day is a national campaign to inspire you to begin to prepare for the inevitable, not with fear, but with purpose, love and a sense of legacy.
SWSPHN has developed a dementia and palliative care services directory which contains local, state and national services to guide families, carers and people living with dementia from diagnoses to end-of-life care.
SWSPHN Integration and Priority Populations team members attended the expo. Left to right: Kate Noble, Mele Lokotui, Kirsty Young and Sofi Milosevic.
Pictured below:
Expo attendees appreciated the stalls and information sessions.
04 July 2025
Want to find out how to best support your ageing parents or a loved one with a life-limiting illness?
Did you know you can plan for a good end-of-life when it comes?
Come along to the Dying to Know Day Expo at the Fairfield Youth and Community Centre on Friday, 8 August to:
speak with funeral celebrants, the South Western Sydney Local Health District (SWSLHD) palliative care service, organ and tissue donation services, bereavement services, solicitors and more
join information sessions on various end-of-life topics
get free information, showbags and light refreshments
Dying to Know is a national campaign to inspire you to begin to prepare for the inevitable, not with fear, but with purpose, love, and a sense of legacy.
SWSPHN has again partnered with organisations including SWSLHD and Fairfield City Council to organise the free expo.
We’ll also be hosting a stall where you’ll find valuable information and resources on advance care planning and the importance of making your healthcare preferences known. Stop by and meet our team.
The expo will run from 9.30am to 1pm. The community centre is at 55 Vine Street, Fairfield.
Dementia Australia’s Nightingale Program is a specialist nurse-led support and palliative care service promoting choice, wellbeing and forward planning.
It is available free in locations across NSW, including in South Western Sydney, for people living with advanced dementia, their families and carers.
The program provides palliative care, education, advice and referrals to other services including to specialist palliative care teams for complex end-of-life care.
It works collaboratively with GPs, nurse practitioners, community palliative care teams, existing service providers and all allied health teams.
How it helps
Offering a specialist clinical nurse consultant as the single point of contact, the Nightingale Program develops care strategies to enable people living with dementia to:
stay at home longer and maximise their independence
promote quality of life and positive relationships
have a voice in their future care options and decision making
avoid unnecessary presentations to acute hospital settings
have clinical advice including co-morbidity management, pain management, delirium and palliation
receive advanced dementia care and family support
Its benefits are
specialist, comprehensive nursing assessment and advice
identifying current issues, anticipating changing needs
referrals to other service providers as needed
continuity of care, offering a single point of contact for guidance
consultation in developing advance care planning for future health care needs
education and emotional support for family and carers
The program supports people living in
residential homes
community settings
residential aged care (typically during transition to care or in regional areas)
It is for people who are living with moderate to severe stages of dementia and require palliative support due to a change in symptoms, and in need of palliative support and/or assistance with planning for end-of-life care.
07 February 2025
South Western Sydney PHN (SWSPHN) Integration and Priority Populations Coordinator Kate Noble was selected to join The Dementia 100 panel, a NSW Dementia Expert Advisory Group.
The Dementia 100 panel was created to gather various perspectives on the National Dementia Action Plan 2024-2034 and its implementation in NSW.
The panel consisted of 100 individuals from diverse backgrounds, including people with lived experience, carers, healthcare professionals, researchers and experts from various disciplines.
Kate said the panel was created due to the overwhelming interest from a diverse range of people with lived experience and professional expertise across NSW.
“It was great because it brought together a diverse mix of voices, from a broad range of professions and those with lived experiences,” she said.
“It was valuable to hear perspectives from different sectors and to bring forward ideas on how to make dementia care more responsive and accessible.”
The National Action Dementia Plan 2024-2034 is the Australian Government’s response to the World Health Organisation’s (WHO) Global Action Plan on Dementia, which aims to address the growing challenge of dementia.
According to Dementia Australia, dementia is the leading cause of death for Australian women and the second leading cause of death for all Australians.
In NSW, it is estimated the number of people living with all forms of dementia will increase from 138,200 to 252,800 by 2054.
Australia Institute of Health and Welfare dementia in Australia
The Action Plan includes eight high-level actions aimed at enhancing dementia awareness, decreasing the population’s risk of developing dementia, and improving coordination of services for people living with dementia.
These actions aim to:
promote equity and human rights
tackle stigma, improve awareness and promote inclusivity
empower individuals and communities to minimise risk where they can, and delay onset and progression
improve dementia diagnosis and post-diagnostic care and support
improve treatment, coordination and support for people living with dementia
support carers of people living with dementia
build capability of the workforce to care for and support people living with dementia
improve dementia data, maximise the impact of dementia research and promote innovation
National Dementia Action Plan 2024–2034
“This plan is Australia’s version of the global action plan, and it was essential to have a national response to ensure we are improving dementia care in line with global best practices,” Kate said.
A key highlight of Kate’s involvement was the inclusion of the Greater Choice for At Home Palliative Care Measure in the National Dementia Action Plan, something she had been advocating for.
“One of the things I was most excited about was the mention of the Greater Choice for At Home Palliative Care Measure, in the plan,” she said.
“The Greater Choice for At Home Palliative Care Measure aims to improve palliative care coordination across the health and aged care systems and create links between local hospitals, GPs, palliative care services and aged care providers to improve access to quality palliative care for older people living at home.
“It was great to see the importance of palliative care in dementia care being recognised nationally.”
Kate emphasised people living with dementia need to undertake Advance Care Planning discussions early in the disease progression
“It’s important to have these conversations early, to allow people living with dementia to have control over their choices,” she said.
“This is why including Advance Care Planning in the dementia action plan is so important. It’s about offering people choices—whether they want resuscitation, feeding tubes or other treatments as they approach the end of life.”
Kate’s expertise in dementia care, including her clinical experience and ongoing master’s studies, significantly contributed to her selection for the panel.
“I’ve been involved in dementia care for a long time,” she said.
“I’ve worked clinically in dementia for five years, and I’m doing my master’s in dementia. Which, I think, really helped me stand out and made me an ideal fit for the group.”
With her continued work at SWSPHN, Kate remains committed to ensuring dementia care is integrated into primary health services and includes all populations, especially those in underserved communities.
“I’m proud to have contributed to the National Dementia Action Plan 2024-2034 and seen our local perspectives reflected in the final recommendations,” she said.
“It’s exciting to see the issues I’m passionate about, like palliative care and the integration of dementia services into primary health networks, taken seriously at the national level.”
South Western Sydney PHN’s (SWSPHN) Integration and Priority Populations Coordinator, Kate Noble, was invited to present at the International Dementia Conference at the Hilton Sydney on Thursday, 5 September.
The International Dementia Conference is a biannual conference held over two days with global experts, industry leaders and those with lived and living experiences.
The conference aims to provoke discussions and inspire action among those committed to improving the care of those living with dementia.
This year’s theme, ‘In the Arena’, highlighted the difference between watching the action and being out on the field and, in doing so, giving a platform to those in the arena of complex dementia, palliative care and positive ageing.
Over two days, almost 1,000 people attended the conference to hear from a diverse group of speakers about the latest complex dementia, palliative care and positive ageing research, as well as practice and insights from around the world.
Kate Noble, presenting at the International Dementia Conference
Kate showcased the Peace of Mind Project (POMp), which aims to improve the end-of-life journey for people living with dementia, their carers, families and health professionals by implementing a capacity-building intervention.
POMp was developed by SWSPHN in 2018 as part of the Greater Choice for At Home Palliative Care Measure, which aims to improve palliative care coordination through Primary Health Networks (PHNs).
The Greater Choice for At Home Palliative Care Measure was a four-year pilot program, expected to end in June 2021, but has been extended to 2025 and now includes all 31 PHNs.
During the presentation, Kate spoke about the Capacity Building Model, highlighting the four groups surrounding a person living with dementia: the community, carers, friends and family, general practice, aged care workers, and the South Western Sydney health system.
Kate also highlighted the key barriers reducing access to palliative care for people living with dementia.
“Some key barriers include low dementia literacy and stigma, late diagnosis and late recognition of deterioration and palliative care needs, lack of knowledge and participation in planning in advance for late care needs and wishes, myths and misunderstanding of palliative care and reduced recognition with dementia being a life-limiting disease,” she said.
Other SWSPHN resources and programs were also highlighted during the presentation.
caring@home has released the Prompts for End-of-Life Planning (PELP) Framework, formerly known as the Palliative and End-of-Life Care Framework – Last 12 Months of Life.
The PELP Framework guides proactive, high-quality end-of-life care across all care settings to assist health professionals in delivering person-centred care during the last 12 months of life.
The framework includes prompts which can support:
identification of patients suitable for a palliative approach to care
identification of four clinical end-of-life processes:
advance care planning and person-centred care based on need (at risk of dying)
transition focus of care needs from restorative to palliative (likely to die soon)
terminal care needs (dying)
after-death care (bereavement)
The PELP Framework was developed by caring@home, a National Palliative Care Project funded by the Australian Government, in collaboration with a National Advisory Committee which included GPs, palliative medicine specialists, nurse practitioners and nurses.
During March and April, SWSPHN held a series of Local Health Forums throughout the region.
Community members, health professionals and community service providers were invited to come along to a forum to discuss how to improve the health of our region and ensure we attract and keep quality GPs, and other primary health professionals.
The feedback from these forums will inform the SWSPHN health needs assessment, which explores priorities, service needs, and gaps within our region. It will also contribute to ongoing strategic planning for our Primary Care Workforce team.
We would like to thank everyone who contributed to an outstanding series of forums.
Below is a report which outlines the key findings.
SWSPHN is currently planning the next Local Health Forums which will focus on palliative care and the importance of advance care planning. We look forward to hosting these forums in August and September 2024. Dates to come shortly. If you are interested and would like to attend, please sign up for our Community Pulse newsletter or follow us on our socials to be the first to hear when these forums are announced.
SWSPHN staff gathered to mark National Palliative Care Week and celebrate the launch of the updated version of our A Journey into Sorry Business booklet, on Tuesday, 21 May.
SWSPHN partnered with local Aboriginal Elders, the Gandangara Local Aboriginal Land Council and South Western Sydney Local Health District to develop the booklet which was first launched in 2021.
Staff gather to learn more about Palliative Care Week and celebrate the launch of the updated A Journey in Sorry Business booklet.
A Journey into Sorry Business supports First Nations people to share their wishes and preferences for their end-of-life care through ‘sorry business’ – cultural practices and protocols associated with death.
Staff enjoyed a morning tea and heard from Kate Noble from our Integration and Priority Population team, who holds the palliative care portfolio.
Kate talked about the booklet and how Palliative Care Australia is highlighting the growing need to educate and empower Australians about quality of life towards the end-of-life.
