An individual of any age may be eligible for a referral to the Program. Clients meeting the below criteria may then be considered into the program. Referrals are received through the Triple I (Hub).

1) Client is known to the LHD Palliative Care Service and is admitted to a LHD community based nursing service

2) Client is assessed by referrer utilising the following validated tools:

· Phase Assessment

· Resource Utilisation Groups – Activities of Daily Living (RUG_ADL)

· The Australia-modified Karnofsky Performance Scale (AKPS)⁸

· Symptom Assessment Scale (SAS)

· Palliative Care Problem Severity Score (PCPSS)

· Waterlow Pressure Ulcer Assessment Tool

3) The client must be in the terminal phase of their illness as defined by the clinical assessment with a predicted survival of 7 days or less, Palliative Phase 3 or 4 (deteriorating or terminal) and AKPS ≤ 40.

4) The client must, in the opinion of the referrer, be experiencing burdensome symptoms associated with the terminal illness that require increased level of support, increased care needs, and/or additional carer support to enable the client to remain at home; and

5) Client must have a carer residing with them

6) The client and/or their family have been consulted and are aware of diagnosis and referral.