the Blueprint for Improvement

Intended Outcomes

The Intended Outcomes are statements describing the anticipated and desirable results of implementing the Blueprint. 


Essential Component 1

  • Communities will have an increased understanding of the need for and benefits of quality care for people approaching and reaching the end of their life.
  • Through community engagement and awareness raising, death and dying will be more openly discussed by more people outside of crisis events.
  • An increase in forward planning will be evidenced by the appointment of enduring guardians, the completion of Advance Care Plans, Directives and other legal instruments.
  • There are increased opportunities for earlier and ongoing conversations about end of life issues with health care providers.
  • Communities increasingly recognise the limitations of active treatments when approaching the end of life and consider quality of life in discussing their goals of care.
  • Death is considered a natural event and will be increasingly destigmatised.
  • Community volunteer programs are supported and well-recognised for their contributions. 

Essential Component 2

  • Patients, families and carers are well-informed about their illness and treatment options.
  • Goals for patient, family and carer are defined and appropriately documented.
  • Care providers across all settings are skilled in engaging with patients, families and carers on end of life discussions and setting goals of care.
  • Advance care planning is undertaken and documented.
  • Advance Care Plans are regularly reviewed.
  • Preferred place of care and death is articulated and documented.
  • There is enhanced community awareness, understanding and ability to engage in conversations regarding end of life.

Essential Component 3

  • Patients and families have access to care in a setting appropriate to their needs.
  • Care providers understand the unique contribution they make to the care of people who may be approaching or reaching the end of life, and are supported to fulfil that potential.
  • Care providers have access to the resources and supports required to achieve high quality outcomes.
  • Care providers are supported through the development and dissemination of clinical practice guidelines and pathways.
  • Preventable hospital admissions are reduced.
  • Specialist palliative care providers are structured and resourced to support other services caring for people approaching and reaching the end of life.
  • Skills in caring for people approaching and reaching the end of life are core competencies for all health, aged and community care workers.
  • Support and resourcing for the development of new collaboration initiatives.
  • Non-beneficial or burdensome care is minimised.

Essential Component 4

  • Clinical staff are able to identify those people who may benefit from integrated care as they approach the end of life.
  • Standardised screening tools are available and used.
  • People have an opportunity through early recognition to benefit from enhanced care models.
  • Conversations about goals of care commence earlier to optimise opportunities to align care to those goals.
  • There are earlier opportunities for advance care planning.
  • Negotiated goals of care guide service provision to prioritise quality of life for patients, their families and carers.
  • Liaisons and partnerships are built with other services to provide multidisciplinary and cross-sectoral care.
  • Liaison and coordination with other specialists occur.
  • Patients, carers and families are informed and educated about the expected course of the patient’s illness and can plan for that.
  • Earlier involvement of specialist palliative care services based on assessed need can improve quality of life, potentially improve survival and reduce distress for patients, their carers and families.

Essential Component 5

  • All people receive timely, quality care in the appropriate setting, in accordance with their assessed needs and in consultation with them, their families and carers.
  • Care is delivered in accordance with quality and safety standards.
  • All people are assessed using common assessment tools that identify needs particular to their end of life care.
  • Cultural, spiritual and other values of patients, their families and carers are respected.
  • Partnerships with Aboriginal stakeholders (including Aboriginal Community Controlled Health Services) are fostered to address the health needs and interests of Aboriginal people.
  • Patients’ pain and or other physical symptoms will be effectively controlled.
  • Psycho-social and spiritual support is available and offered.
  • Access to grief and bereavement support is available and offered.
  • Patients, families and carers are provided with appropriate equipment to ensure a safe home environment.

Essential Component 6

  • People are able to receive care aligned with their goals as they transition between settings of care (i.e. hospital, home, aged care).
  • Care is well coordinated and support is provided to patients, carers and families to assist in navigating health and community care systems.
  • Care providers across all settings have an understanding of their unique roles and are skilled in providing care to people as they approach and reach the end of their lives.
  • Clinical handover of care is optimal and supported by clear communication and clinical tools.
  • Changes in care requirements are identified and responded to appropriately.
  • Formalised referral and access arrangements support the patient’s transitions of care.
  • Clinical information to support seamless care is available at the point of care.
  • Transfer of care occurs in consultation with patients, families, carers and care providers across all settings.

Essential Component 7

  • All people in NSW have access to services and health professionals that have the necessary skills and expertise to meet their needs.
  • A networked approach to care (referral, education, data and research) connects specialist palliative care services with other care providers across all care settings.
  • Best available evidence informs clinical practice.
  • Care providers across all settings know when and how to access specialist palliative care services.
  • Shared care arrangements are fostered between specialist palliative care providers and other care providers across all settings.
  • Unplanned hospital admissions are reduced.
  • Specialist palliative care services are resourced to provide networked support across the system.
  • Ongoing access to specialist palliative care services is based on regular assessment of need and adapts to these accordingly.

Essential Component 8

  • Timely recognition of the imminently dying person occurs.
  • Quality care in the last days of life is safe, effective, responsive and appropriate.
  • Care is provided in the most appropriate environment as close to home as possible in accordance with the needs of patients and in consultation with them, their families and carers.
  • Patients, families and carers are provided with information and support.
  • Care plans are developed, implemented and reviewed regularly to support people who are imminently dying, their families and carers.
  • Preventable transfer of patients who are imminently dying is avoided.
  • Patients and care providers across all settings have access to 24-hour-a-day, 7-day-a-week support.

Essential Component 9

  • Grief and bereavement support is available.
  • Family members, carers and significant others are supported as they grieve.
  • Care providers across all settings are supported and resourced to support carers and families through their loss and grief.
  • Bereavement services are recognised as an essential component of care to family and carers.
  • Bereavement services are resourced and are a routine part of palliative and end of life care.
  • There are models and guidelines to support best practice in bereavement services including bereavement risk assessments.

Essential Component 10

  • Access to and use of high quality patient-level data informs efforts to improve patient experiences and outcomes.
  • Access to and use of high quality service-level data informs efforts to improve care coordination and integration.
  • Access to and use of high quality system-level data informs efforts to improve funding models, planning and policy development.
  • Medical records are electronically integrated and available across all care settings at the point of care throughout NSW.
  • Clinical information is available at the point of care in all care settings.
  • Access to and use of high quality data supports effective benchmarking and service evaluation.
  • Access to and use of high quality data enhances quality improvement outcomes and research.