The Palliative Aged Care Outcomes Program (PACOP): establishing a national framework to improve palliative care in long-term care facilities for older people

Abstract

Background

With an aging population worldwide, many countries face increasing challenges in delivering quality palliative care in long-term care facilities for older people (LTCFs). In Australia, a Royal Commission into Quality and safety of Aged Care in 2021 highlighted significant gaps in this field. In response, the Palliative Aged Care Outcomes Program (PACOP), a person-centred outcomes framework, was developed to address gaps in identification, assessment and management of palliative care needs in LTCFs.

Objective

To present the development, implementation and early process evaluation of PACOP.

Design

A cross-sectional mixed-methods study with embedded qualitative open-ended questions.

Methods

PACOP was co-designed with sector stakeholders and informed by insights from the Palliative Care Outcomes Collaboration (PCOC)-Wicking trial. Launched in 2022, it comprises two key components: the Profile and Outcomes Collections, supported by national benchmarks, improvement facilitators, training, data and IT infrastructure. A process evaluation, guided by Normalisation Process Theory (NPT), used the NoMAD instrument and open-ended questions to explore healthcare workers’ experiences of the PACOP implementation.

Results

By June 2025, 440 of 2,622 (16.8%) LTCFs in Australia participated in PACOP. Key facilitators included organizational buy-in, leadership support, the train-the-trainer model and improvement facilitators. Participants reported that PACOP improved early identification of residents’ palliative care needs, supported structured care planning and informed service improvement. However, challenges such as workforce instability, inexperienced staff and limited IT integration were identified.

Conclusion

PACOP has achieved substantial uptake and early signs of successful implementation in Australian LTCFs. Continued investment in organizational systems change, tailored training, digital integration, along with responsive benchmarking and feedback mechanisms, are essential to sustaining its implementation and enhancing palliative care quality in LTCFs.

Background

Population ageing places a significant challenge on health and social care systems, with the number of people aged 65 years and over projected to reach 2.2 billion globally by 2070 [1]. This demographic shift is accompanied by a growing demand for aged care services. In Australia, the proportion of individuals aged 65 and over is expected to increase from 17% in 2022 to between 25% and 27% by 2071 [2]. The number of individuals residing in long-term care facilities (LTCFs) in Australia increased by 9.5% between 2013 and 2023 (from 169,000 to 185,000 people) [3].

Older adults living in LTCFs in developed countries consistently experience a high burden of symptoms due to aging-related physiological changes, significant frailty, multimorbidity and complex health conditions [4]. An Australian population-based study reported that 92% of residents potentially had palliative care needs prior to their death [5], underscoring the growing importance of structured palliative care approaches in LTCFs [6].

Several countries have developed national initiatives to improve the delivery of palliative care in LTCFs (also described as residential aged care facilities, nursing homes, care homes or rest homes according to differing national terminologies). For example, the United Kingdom’s Gold Standards Framework provides a systematic and evidence-based approach to enhancing end-of-life care in LTCFs and other settings [7]. In Canada, the use of interRAI Palliative Care assessment system enables standardised resident assessments and supports national benchmarking in long-term care [8]. In New Zealand, the Palliative Outcome Initiative (POI) is widely implemented across LTCFs and primary care services to support the delivery of high-quality palliative care [9].

The impetus for similar developments in Australia was the 2021 Royal Commission into Aged Care Quality and Safety which identified numerous shortcomings in the end-of-life care provided to older adults residing in LTCFs [10]. In response, the Australian Government introduced a series of sector-wide initiatives, including the Australian National Aged Care Classification (AN-ACC) funding model to better align funding with care needs [11], mandatory 24/7 registered nurse coverage in LTCFs [12] and revisions to the Aged Care Quality Standards to embed person-centred and culturally safe care [10]. Additionally, national efforts have emphasised the importance of comprehensive assessments and the development of person-centred quality indicators to support continuous improvement across aged care settings [10]. Palliative care was identified as one of four priority areas requiring urgent reform—including the need to improve recognition of deterioration and delivery of palliative care to residents approaching the end of life [10].

Person-centred outcome measurement (PCOM) initiatives play a crucial role in evaluating and improving care quality by enabling timely identification of palliative care needs, optimising symptom management and guiding advance care planning [13]. International evidence suggests that structured outcome measurement frameworks improve clinical decision-making, reduce unnecessary hospitalisations and enhance person-centred care [14]. However, despite the increasing demand for palliative care within LTCFs and the proven benefits of PCOMs-based programs in palliative care settings, structured PCOMs systems remain underutilised in LTCFs [10]. In Australian hospital- and community- based specialist palliative care settings, the Palliative Care Outcomes Collaboration (PCOC) serves as a well-established framework, demonstrating how a structured PCOMs-based program can inform individual patient’s care, facilitate benchmarking and continuously improve the quality of palliative care to drive significant improvements in patients’ outcomes [15]. Given the high symptom burden and complex care trajectories in aged care, a structured PCOMs-based framework in Australian LTCFs may facilitate similar improvements to those demonstrated through PCOC in hospital- and community-based palliative care [16].

Directly implementing the PCOC framework in LTCFs was not a viable option due to differences in workforce capabilities and care structures [17]. Unlike specialist palliative care services, which are staffed by multidisciplinary teams with advanced expertise in symptom management and end-of-life care, LTCFs typically lack dedicated palliative care teams and care is largely delivered by generalist aged care staff with varying clinical skill mixes and palliative care knowledge in particular [10, 18]. Furthermore, the point at which the need for palliative care is recognised and commenced is variable and, in some instances, may not occur at all. These fundamental differences limit the applicability of PCOC in LTCFs, highlighting the need for a tailored and structured model that aligns with the workforce capabilities and care delivery processes.

To address these challenges and support primary palliative care in LTCFs, the Palliative Aged Care Outcomes Program (PACOP) was established in 2021 with funding from the Australian Government Department of Health, Disability and Ageing to align with other reforms being implemented in response to the Royal Commission [10]. As a sister program to PCOC, PACOP provides a structured, person-centred palliative care framework specifically designed for LTCFs. By enabling routine assessment, early identification and management of palliative care needs, benchmarking and continuous improvement, PACOP seeks to enhance palliative care delivery within aged care settings, ensuring residents receive timely, high-quality and person-centred care. This paper outlines the development and national implementation of PACOP and reports early findings from a process evaluation examining its integration into routine aged care practice to support quality improvement in an era of rapid aged care reform in Australia.

Methods

This study employed a two-phase approach. Phase I described the development of PACOP and implementation strategies, while phase II involved a process evaluation of PACOP implementation guided by Normalization Process Theory (NPT) [19]. This evaluation utilised the Normalization MeAsure Development (NoMAD) questionnaire along with two-open questions to collect healthcare workers’ experiences and feedback on routine use of PACOP in LTCFs [20].

Phase I: PACOP development and implementation strategies

Established in 2021, PACOP is a national initiative which aims to improve the quality of palliative and end-of-life care in LTCFs in Australia. Guided by the mission of providing optimal palliative and end-of-life care for all Australians and their families receiving aged care services, PACOP builds upon the foundational framework of PCOC [21] and lessons from the PCOC-Wicking trial (2019–2021) which tested outcome monitoring in aged care settings [17].

Program conceptualisation involved extensive national consultation with aged care providers, researchers, government representatives, policy advisors and peak bodies. Stakeholder feedback directly informed the selection and refinement of assessment tools, protocols and implementation strategies to ensure a contextually appropriate, scalable and practical model. Subject specific working groups and workshops informed the development of the PACOP clinical framework, the data items and architecture, the improvement facilitator model, the education framework and the LTCF engagement and recruitment strategy. The assessment component was trialled by six LTCFs over a four-week period. Comprehensive feedback about use of the individual assessments with 33 residents informed minor modifications to wording and details within some questions. The final framework was designed specifically to meet the complexity of LTCFs where frailty, cognitive impairment and multimorbidity are common, and primary palliative care [22] is predominantly delivered by generalist nursing staff and care workers.

Governance structure and stakeholder engagement

PACOP is guided by a Management Advisory Committee (MAC) with representation from an aged care organisation, palliative care, geriatric and general practice academic and clinical leaders, researchers, consumers and University governance. A Clinical Advisory Committee (CAC) includes aged care clinical leaders, representatives of the Australian Government Department of Health, Disability and Ageing and PACOP senior team members. The MAC has a strategic development and governance function, while the CAC provides clinical guidance on tools, benchmarks and implementation strategies. This governance model was adopted to ensure responsiveness to both policy and clinical developments in LTCFs. PACOP maintains extensive partnerships with palliative and aged care education organisations and specialist palliative care services nationwide.

The PACOP model of care

PACOP consists of two core, interrelated components: the Profile Collection and Outcomes Collection [23]. The Profile Collection is implemented for all residents in participating LTCFs to enable the early identification of residents with palliative care needs. The Outcomes Collection is initiated once a resident is identified as requiring palliative care. Supplementary Table 1 lists the assessment components for Profile and Outcomes Collections.

The Profile Collection and the early identification of palliative care needs

The Profile Collection uses a combination of routine assessments, clinical tools and embedded decision-making criteria to track the wellbeing of residents and guide staff in determining when a resident would benefit from palliative care. A comprehensive three-part clinical assessment is undertaken on admission to the LTCF and every three months. A Deteriorating Resident Tool (DRT) [24] facilitates assessment of residents at any other time when staff notice clinical deterioration or are concerned about changes in the resident’s condition.

Assessments are based on five validated clinical assessment tools: PCOC Symptom Assessment Scale (SAS) for resident symptom distress [25], Palliative Care Problem Severity Score (PCPSS) for symptom severity [26], Australia-modified Karnofsky Performance Status (AKPS) for function performance [27], the Rockwood Clinical Frailty Scale (RCFS) for frailty [28] and the Resource Utilisation Group Activities of Daily Living (RUG-ADL) for dependency and the resources required for care [29]. Supplementary information relating to the main reasons the resident needed care, social interaction, hospitalisations and advance care planning is also gathered (Supplementary Table 1). Assessment information is used to inform care planning and the early identification of residents with palliative care needs. The PACOP Clinical Guide outlines a structured Decision Flowchart designed to assist clinicians in making this determination (Supplementary Fig. 1).

The Outcomes Collection and palliative and end-of-life care (The PACOP Assess, Respond and Plan protocol)

The ongoing assessment and monitoring of residents with palliative and end-of-life care needs occurs in the Outcomes Collection through the implementation of the Assess, Respond and Plan protocol (available on request). This protocol provides a structured framework for outcome monitoring and a systematic process for escalating clinical review, drawing on existing aged care workforce structures. On commencement of the Outcomes Collection, a comprehensive clinical assessment is completed using the assessment tools used in the Profile Collection (excluding the RCFS) with the addition of the Palliative Care Phase to determine the urgency of clinical response required [30]. Assessment frequency is guided by the resident’s allocated Phase, with full clinical assessments required weekly for Stable/Deteriorating phases and daily for Unstable/Terminal phases. Daily monitoring of symptom distress is undertaken using the PCOC SAS, with an escalation protocol for care staff to notify registered nurses or supervisors when thresholds are met. Specified thresholds, for example, PCOC SAS scores ≥ 8 or PCPSS scores of 3 prompt urgent clinical review, possible phase change and escalation of care. Care plans are then updated to ensure alignment with care needs, symptom trajectory and resident goals.

Data infrastructure

Collection and electronic documentation of assessment data and six-monthly submission to PACOP for analysis and reporting are key components of participation in the program. A data dictionary describes all data elements and submission criteria. PACOP supports participating LTCFs by providing palCentre [31] to collect, store and extract data. To support integration with existing care management systems, PACOP also collaborates with IT vendors to embed assessment specifications into provider platforms.

Benchmarking—development, reporting and quality improvement

PACOP’s national benchmarking framework, built on Profile and Outcomes Collection data, enables services to assess performance over time, compare results within and across services and against national standards, and to identify areas for improvement [32]. Thirteen co-designed benchmarks focus on timeliness, care planning and symptom management (Supplementary Table 2). Participating LTCFs receive confidential biannual reports with national and longitudinal comparisons, supported by Communities of Practice and targeted workshops for data interpretation, peer learning and quality improvement planning.

Implementation strategies

The implementation of PACOP is guided by Research Implementation in Health Services (i-PARIHS) framework [33], which identifies the interaction of the Innovation (I), engagement of recipients (R), a supportive context (C), and active facilitation (Facn) as key components for successful implementation of an intervention. Strategies developed by PACOP integrate facilitation, capacity building and contextual adaptation to support effective uptake and sustainability in LTCFs.

A dual facilitation model was used. External improvement facilitators (IFs) deliver education, support interpretation of outcomes data and foster collaboration through regular follow-up and Communities of Practice (CoPs). Initial education was delivered through full day face-to-face workshops and virtual sessions, typically conducted during paid working hours to maximise staff participation, with scheduling adapted to local operational requirements. Initial training generally required approximately 2 h per site, followed by ongoing support and refresher activities embedded within routine implementation processes.

A train-the-trainer approach enables local staff to lead ongoing training and act as program champions within LTCFs. Senior staff are appointed by LTCFs as internal facilitators to lead implementation, embed PACOP into routine workflows and promote staff engagement.

Capacity building focuses on strengthening staff capability to apply assessment tools to identify needs, guide care and inform real-time quality improvements. Self-directed eLearning modules complemented facilitator-led education and supported ongoing learning and sustainability over time. To ensure contextual fit, implementation was aligned with existing systems, workflows, policies, and organisational structures, deliberately embedding the program to foster ownership, strategic alignment, and sustained use across diverse LTCFs.

Phase II: a process evaluation of the routine use of PACOP in LTCFs

Aims

A process evaluation was conducted to support the sustainability and further scale-up of the PACOP program, gain insights and learn lessons from participating LTCFs regarding the routine use of the PACOP program.

Study design

A cross-sectional survey with two embedded open-ended questions was conducted in April to May 2024, approximately 18 months after the formal launch of the program. The study was guided by the NPT, a widely used theoretical framework for understanding how complex interventions are implemented, embedded and integrated into routine clinical practice [19]. The NPT offers a robust lens for evaluating the efforts of individuals and teams in normalising new models of care.

Measurement tool

The NoMAD instrument, which includes two sections and is based on NPT [20], was designed by the NPT research team to assess factors that influence the normalisation of interventions from the perspective of implementation participants. To evaluate the PACOP implementation process, authors LB, CJ and BA initially adapted each item of the NOMAD instrument to align with the PACOP context. The adapted version was subsequently reviewed by all the authors until consensus was achieved. The modified NoMAD instrument (Supplementary file 1) used in this study includes two sections. Section A examined participants’ perceptions of PACOP (0 to 10 scale, with higher scores indicating more positive attitudes), while Section B explores healthcare workers’ experiences with the routine use of PACOP through NPT’s four core constructs: coherence (Making sense of implementation), cognitive participation (Commitment and engagement), collective action (Integration into routine practice) and reflexive monitoring (Evaluating and refining for sustainability) [19]. Two open-ended questions were included in the survey to elicit participants’ suggestions for program improvement: (1) What suggestions might improve PACOP training within your LTCF? (2) What suggestions could improve support for staff using PACOP in their role?

Participants and settings

LTCFs were invited to participate if they had submitted data to PACOP or had implemented the PACOP framework for a minimum of 6 months. Key contacts (n = 117) from 58 LTCFs from seven Australian jurisdiction were invited to participate and share the survey with their staff. Among these LTCFs, six had fewer than 40 licensed beds, 26 had between 41 and 100 beds, and another 26 had more than 100 beds.

Data collection

Two strategies were employed for data collection. First, survey invitations were sent via email to LTCF managers, who were asked to forward the survey to their healthcare staff. Second, the PACOP team promoted the survey informally during regular meetings and through CoP groups involving participating LTCFs. Participation was voluntary, and responses were anonymous to encourage honest and reflective feedback.

Data analysis

Quantitative data were analysed using SPSS Version 30.0 and were presented as frequencies and percentages. Responses to the open-ended questions were analysed thematically using an inductive approach to identify common suggestions and concerns raised by participants. Given the modest volume of qualitative data, one author (YD) initially coded the feedback into themes aligned with the survey questions using an Excel matrix. A second author (CJ) reviewed and refined the themes to ensure clarity, coherence and representativeness.

Results

National uptake and scale-up of PACOP implementation

PACOP was initially piloted in eight LTCFs over 18 months from 2019 to 2021 during which it was referred to as the PCOC Wicking Trial. Based on pilot outcomes and ongoing feedback, the framework was further refined between July 2021 and June 2022. PACOP was formally launched in October 2022. Supported by national funding since November 2021, PACOP has expanded significantly in both clinical uptake and its development as a fully operational quality improvement program. By June 2025, a total of 440 LTCFs were registered with PACOP. Fig. 1 presents the LTCFs registrations and routine data submissions from July 2021 to June 2025.

Fig. 1.

Trends in long term care facilities (LTCFs) registration with PACOP (6 monthly and cumulative registrations) and number of data reporting LTCFs (Jul 2021 – Jun 2025)

Healthcare workers’ survey findings

Participant characteristics

A total of 117 healthcare workers from the 58 LTCFs were invited to participate, of whom 62 LTCFs healthcare workers completed the survey (response rate: 53.0%). The majority were female (83.9%), aged between 26 and 55 years (43.5%), and held postgraduate qualifications (62.9%). Just over half (54.8%) were born overseas. Full demographic details are provided in Table 1.

Table 1.

Demographic information of the participants (N = 62)

Demographic information		N (%)
Age (Range)	≤ 35	20 (32.3%)
	36–55	27 (43.5%)
	> 55	15 (24.2%)
Sex	Female	52 (83.9%)
	Male	10 (16.1%)
Education Level	Postgraduate degree	39 (62.9%)
	Undergraduate degree	13 (21.0%)
	Year12, Higher School Certificate	3 (4.8%)
	VET/TAFE Certificate IV and Other	7 (11.3%)
Country of Birth	Australia	28 (45.2%)
	Overseas	34 (54.8%)
Preferred Language Spoken at Home	English	47 (75.8%)
	Non-English	15 (24.2%)
The years of experience working in LTCFs	6 + years	44 (71.0%)
Roles in LTCFs	Care workers	30 (48.4%)
	Clinical/health professional staff	9 (14.5%)
	Managers/clinical supervisors	23 (37.1%)

Perceptions of PACOP and anticipated normalisation (NoMAD section A)

Participants reported a mean familiarity score of 7.82 for PACOP (median = 8). The mean score for expecting PACOP to become a routine part of their work was 8.10 (median = 8), while the mean score for its current integration into daily practice was 6.32 (median = 6). These results are illustrated in Fig. 2.

Fig. 2.

Healthcare workers’ perceptions of PACOP normalisation, familiarity and future integration (NoMAD Section A)

Experience of PACOP implementation (NoMAD Section B)

The NoMAD Section B examined how healthcare workers understood, engaged with, operationalised and appraised PACOP in LTCFs across the four NPT constructs (Fig. 3). For Coherence (Understanding and making sense of PACOP implementation), most participants recognised PACOP’s distinct purpose and value, though fewer (65%) reported a shared understanding across their teams. For Cognitive Participation (Commitment and engagement to PACOP implementation), engagement was high, with the majority willing to support implementation, viewing participation as a legitimate part of their role and identifying local champions. Regarding Collective Action (Integrating PACOP into routine practice), more than 80% felt confident using PACOP, but fewer perceived training (60%) and resources (70%) as adequate, and around 20% expressed concern about potential disruption to work. For Reflexive Monitoring (Evaluating and refining for sustainability), feedback was largely positive, with most believing PACOP improved palliative care and benefited their work.

Fig. 3.

Healthcare workers’ experience with the routine use of PACOP (NoMAD Section B)

Suggestions for improving PACOP training and implementation support (open-ended feedback)

A total of 26 healthcare workers provided responses to the open-ended question regarding PACOP training and implementation support. Thematic analysis identified nine key themes, grouped into two overarching domains: (1) Training needs and preferences, and (2) Implementation support in practice. Illustrative quotes are provided in Table 2.

Table 2.

Themes and illustrative quotes on PACOP training and implementation support

Themes	Summary of feedback	Representative Quotes
(1) Training needs and preferences
Theme 1: Accessibility and ongoing training	Staff suggest more accessible and regular training, including onboarding for new staff and annual refreshers.	“Orientation to PACOP 1-hour session online for new staff.” “Yearly refresher course required please.” “Having a package of training that can easily be sent to a new staff member by email.”
Theme 2: Training format and delivery	Staff prefer shorter, face-to-face or on-site sessions over long webinars.	“Too much to absorb in 8 h.” “Most of our staff are more engaged with face-to-face training.”
Theme 3: Content and Relevant	Training should better explain clinical relevance and benefits to staff/residents.	“Better understanding of practice versus ‘another set of forms’.” “More evidence around how this assists staff, residents and families.”
(2) Implementation support in practice
Theme 4: Implementation and System-Level Support	Leadership, stability and funded roles are seen as critical to sustainability.	“Committed leadership is essential.” “Unstable workforce in WA… Clinical Educator role should be funded”
Theme 5: Integration with Clinical Systems	Staff emphasised the need to integrate PACOP with existing digital platforms.	“Get PACOP into [commercial electronic care management system].” “It’s not integrated into our clinical IT systems, so it is another platform for our staff to learn. Hopefully it can be in the future.”
Theme 6: Notifications and Data Prompts	Suggestions for automated alerts/reminders to ensure assessments are completed on time.	“Can the team implement measures that will send a direct notification…” “Different way to alert staff to review PACOP outcomes.”
Theme 7: Report Use and Data Literacy	Staff want guidance on interpreting reports and understanding how data improves care outcomes.	“We would like further training or understanding of how to read and utilise the reports.” “More training and feedback on how PACOP can improve outcomes.”
Theme 8: Collaboration with External Bodies	Regional support and partnerships with Primary Health Network (PHNs) could enhance reach and consistency.	“Work more closely with the PHN to promote training.” “There is good engagement with PHN and RACFs in our district.”
Theme 9: Governance and Quality Monitoring	Staff suggest aligning PACOP with governance processes, including reporting structures and audit trails, to support evaluation and accountability.	“Include quality measures in clinical governance” “Reportable outcomes monthly”

Discussion

This study presents the development, national implementation and early evaluation of PACOP implementation, a structured and person-centred outcomes framework designed to address gaps in the identification, assessment and care planning for palliative care in LTCFs. While the results are specific to Australia, it provides insights that are relevant to countries with comparable long-term aged care systems.

The rapid growth of PACOP from eight LTCFs in December 2021 to 440 (16.8% of all LTCFs in Australian) by mid-2025 demonstrates the program’s feasibility and broad sector acceptance, reflecting a growing commitment among LTCF leaders to systematically integrate palliative care approaches.

Staff engagement across all levels, supported by organisational leadership and the active involvement of local champions and care managers, was a key enabler of PACOP implementation. Strong staff buy-in indicates that PACOP was perceived as meaningful and aligned with their professional care values. Consistent with previous implementation research [34, 35], leadership support and frontline ownership were essential for embedding this complex intervention into routine practice. Similar enablers have been reported internationally in the implementation of structured, outcomes-based quality improvement programs in long-term care [36, 37], highlighting the need for coordinated, multi-level engagement strategies when implementing quality improvement frameworks in aged care.

The train-the-trainer model and communities of practice were also recognised as effective strategies for building local capacity and sustaining momentum, consistent with findings from other large-scale implementation programs [38]. These approaches encourage peer learning and local ownership [39]. However, participants identified the need for shorter, targeted refresher education sessions, greater emphasis on clinical relevance and practical application of PACOP data. These findings suggest that ongoing, flexible training approaches are essential to accommodate high staff turnover and ensure long-term program fidelity and sustainability.

Digital infrastructure was identified as an enabler to implementation and a lack of digital integration acted as a barrier. While PACOP’s freely available palCentre platform provided a standardised method for data entry, its lack of integration with existing electronic clinical systems in LTCFs created additional administrative burdens and reduced workflow efficiency. Similar challenges have been observed in other person-centred outcome initiatives, where fragmented IT systems hindered collective action and long-term sustainability [34]. Participants also suggested adding automated alerts and reminders to facilitate timely assessments, highlighting the need for greater digital integration to support efficient practice.

Aged care workforce instability, characterised by high turnover, casual employment and staffing shortages remains a significant barrier, disrupting training continuity and undermining consistency in program delivery [40, 41]. Observations from PACOP improvement facilitators suggest that frequent use of newly graduated, inexperienced staff in LTCFs, and discomfort with discussing death and dying may also pose challenges in some settings, although these were not raised directly by healthcare workers. Similar barriers have been reported in other studies conducted in Australia where there is a reliance on international healthcare workers [42]. Addressing these systemic issues will require targeted strategies and organisational change initiatives for the development of a workforce skilled in managing the palliative care needs of individuals approaching the end of life and in communication about death and dying.

PACOP has shown clear benefits at both individual and organisational levels. From the perspective of healthcare workers, PACOP enhanced the timely identification of residents’ palliative care needs, provided a standardised framework, processes for assessment and care planning and increased confidence in delivering palliative care. Reflexive monitoring [19], supported by ongoing feedback of outcomes, allowed staff to see tangible improvements which reinforced their commitment to the program. Continued engagement with the PACOP improvement facilitators and communities of practice supported and sustained systems-change. At the organisational level, PACOP supported benchmarking informed service-level improvements and aligned closely with Australian national aged care reforms [10], strengthening its relevance and sustainability. In contrast to other national initiatives, PACOP is distinguished by its comprehensive framework which includes a facilitation model, staff education, a clinical assessment, planning and response protocol, national implementation of palliative-specific outcome measures, routine data feedback and benchmarking at the LTCF, regional and national levels. These features contribute to PACOP’s relevance within Australia, as well as offering transferable insights for comparable countries seeking scalable, sustainable, outcomes-driven models to improve palliative care in LTCFs.

Strengths and limitations

A key strength of the PACOP Framework lies in its national scope and co-design approach which ensured that PACOP is contextually relevant and responsive to the needs of the sector. The mixed-methods study design, incorporating quantitative NoMAD data and qualitative feedback, provided a comprehensive understanding of the routine use of PACOP and lessons for its sustainability. However, the study is limited by its cross-sectional design, small sample size and reliance on self-reported data, which may introduce participant bias. Nevertheless, insights from frontline staff involved in the early PACOP implementation can inform further refinement of the program. Furthermore, as an early evaluation (i.e., just two years into PACOP's national roll-out), the study does not capture the long-term impact of PACOP on resident outcomes or its sustainability over time.

Conclusion

PACOP has demonstrated national feasibility and acceptability, delivering clear benefits for quality palliative care in aged care. While developed in Australia, it offers insights applicable to other long-term care systems. By integrating a standardised care framework with structured outcome measures and strong implementation support, PACOP presents a scalable approach to improving palliative care. Sustained impact will depend on continued investment in training, digital integration, workforce development, and supportive organisational culture.

Authors’ contributions

C.E.J., Y.D., N.J., and K.T. prepared the main manuscript text. Y.D. interpreted the results. All authors (C.E.J., Y.D., L.B., N.J., B.A., K.T., J.W., A.C., and K.E.) critically revised the work, reviewed the manuscript, and approved the final version.

Funding

This work was supported by the Department of Health, Disability and Ageing.

Data availability

The datasets used and analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

PACOP is approved by the New South Wales Population and Health Services Research Ethics Committee (Ref number: 2024/ETH02363). This evaluation was conducted with ethical approval from the Greater Western Human Research Ethics Committee (Ref number: 2021/ETH12021). All procedures were conducted in accordance with the Declaration of Helsinki. For Aged care home staff surveys, submission of survey implied informed consent.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.