1. Identification of patients for eligibility at standardised transitions in the illness course | |
2. Initial hospital based palliative care consultation, addressing: | |
 (a) Review of underlying disease management | |
 (b) Screening for symptom distress | |
 (c) Screening for psychological distress | |
 (d) Review of informal social supports | |
 (e) Review of formal community supports, including local community palliative care | |
 (f) Providing information | |
 (g) Advance care planning discussions | |
 (h) Involvement of family carer, including enquiry of concerns, needs for information | |
3. Regular follow-up, at minimum monthly for minimum of 3 months | |
4. Case conference with the general practitioner within 28 days, addressing | |
 (a) Current and anticipated problems | |
 (b) Recommended management and therapies | |
 (c) Designation of responsibility for different aspects of care |