Delivering services for Support at Home

End-of-Life Pathway

The End-of-Life Pathway supports older people who are approaching the end of life and wish to remain at home. The pathway complements existing state and territory palliative care services by providing in-home aged care support, such as personal care, domestic assistance and nursing care.

About the pathway

The End-of-Life Pathway provides access to in-home aged care services to help eligible participants remain at home during their final stages of life. 

Once a participant enters the End-of-Life Pathway, they remain on the pathway for a 12-week period. 

Where needed and funding remains, services can continue for up to 16 weeks. 

Older people are eligible for the pathway if they meet all the following criteria: 

  • they are aged 65 years or older (or 50 years or older if they are an Aboriginal or Torres Strait Islander person, or homeless or at risk of homelessness) 
  • a medical practitioner or nurse practitioner has certified an expected prognosis of approximately 3 months or less to live 
  • they have an Australian-modified Karnofsky Performance Status (AKPS) score of 40 or below, meaning they spend more than half of each day in bed. 

Eligibility must be supported by an End-of-Life Pathway Form completed by a medical practitioner or nurse practitioner and verified as part of the assessment process. 

An older person can access the End-of-Life Pathway once through the Support at Home program.

The Australian Government is extending the End-of-Life Pathway

From 8 March 2027, the End-of-Life Pathway will be extended to provide continued support for participants who remain living at home after the initial 12 weeks. There are no changes to eligibility criteria or arrangements for accessing the pathway. 

Participants will automatically continue the pathway for a further 12 weeks without the need for reassessment and receive additional funding of approximately $25,000. 

Accessing the pathway

Older people can access the End-of-Life Pathway once through Support at Home. 

Older people who are not currently accessing Support at Home services must get an aged care assessment to determine eligibility. 

Participants receiving Support at Home services can be considered for the pathway through an urgent Support Plan Review. 

The older person must meet the pathway eligibility criteria, supported by an End-of-Life Pathway Form completed by a medical practitioner or nurse practitioner. 

  1. The older person, a family member, carer, provider or doctor can download the End-of-Life Pathway Form for discussion and completion. 
    1. For current Support at Home participants, the completed form should be provided to their provider. 
    2. New Support at Home participants should apply for an online assessment and provide the form to their assessor. 
  2. You  can submit a request for an urgent Support Plan Review through the My Aged Care Service and Support Portal if supporting a current participant. 
    1. Once a new Notice of Decision and support plan are received, the referral can be accepted in the My Aged Care Service and Support Portal and you can notify Services Australia. 
  3. New participants with a Notice of Decision will need to choose a provider and have them accept the referral in the My Aged Care Service and Support Portal. 
    1. You will also need to ensure the new participant has a service agreement in place before service delivery begins. 

 Australia‑modified Karnofsky Performance Scale (AKPS) 

The Australia‑modified Karnofsky Performance Scale (AKPS) is a measure of a person’s overall performance status or ability to perform daily living activities.  

It is a single score, between 10 and 100, assigned by a clinician based on observations of a patient’s ability to perform common tasks related to activity, work and self-care. 

For example: 

  • A score of 100 signifies normal physical abilities with no evidence of disease. 
  • Decreasing scores indicate a person’s reduced ability to perform daily living activities. 
  • A score of 40 indicates that the person spends more than half the day in bed due to advanced disease progression and limited mobility.   

These requirements are consistent with the current palliative care entry pathway for residential aged care. 

Take up period 

Once the End-of-Life Pathway is approved, the older person must start services with a provider within: 

  • 56 calendar days of approval, or 
  • 84 calendar days of approval if a 28-day extension has been approved through My Aged Care. 

If services have not started by the deadline, the approval will end. The older person will need a new assessment before they can be considered for the End-of-Life Pathway again. 

The deadline is based on the approval date shown in the older person’s Notice of Decision letter. The deadline is not shown in the My Aged Care Service and Support Portal. You can view it in the Services Australia PRODA portal. 

Funding 

The pathway provides access to funding of approximately $25,000. 

For existing Support at Home participants, approval of the pathway replaces their ongoing services classification. 

Funding can be used on services available on the Support at Home service list. It is separate from other Support at Home classifications and cannot be accrued. 

Unspent End-of-Life Pathway funds do not carry over to an ongoing services classification if a participant remains in the program after their End-of-Life Pathway funding period ends. 

Services you can deliver 

End-of-Life Pathway participants can access services approved in their Notice of Decision and support plan, in line with the Support at Home service list.   

Participants may be able to access  assistive technology funding through the Assistive Technology and Home Modifications (AT-HM) scheme. Participants with an assessed need for assistive technology will receive their assistive technology funding allocation when they are approved for the End-of-Life Pathway. 

Home modifications funding is not available to participants. The only exception is where approved home modifications have already started before the participant entered the pathway. In these cases, the home modification that has started can be completed. 

Assistive technology funding is available for the standard 12-month funding period. If a participant moves to a Support at Home ongoing services classification after the End-of-Life Pathway ends, they can continue to access remaining assistive technology funding. 

Relevant participants can also access Aboriginal and Torres Strait Islander health workers or practitioners on this pathway, in addition to support to engage in cultural activities.  

Learn more about Support at Home services. 

Care management 

Care partners must deliver care management activities to all participants.   

Care partners should collaborate on a care plan with the participant and their family or supporters.   

In addition to standard activities, care partners should ensure that there is communication and coordination between the participant’s medical team, their family or supporters, and any other palliative care services.  

Unlike ongoing services, you claim care management against a participant’s End-of-Life Pathway funding account. There is no cap on what can be claimed for care management under the End-of-Life Pathway. Care management amounts should be agreed between the provider and participant and should be proportionate and in the participant’s best interests. 

Learn more about care management. 

Accessing other palliative care services 

There are government funded palliative care services in every state and territory. The End-of-Life Pathway is designed to complement but not fund these services.  

For example, a participant may access specialist palliative care nurses and medication management through a state-based program while using the End-of-Life Pathway to get meals and personal care services.   

A list of state and territory based palliative care schemes is available in Chapter 15 of the Support at Home program manual.  

An older person can access the End-of-Life Pathway while accessing voluntary assisted dying. 

Participant contributions 

Participants must contribute to the cost of their independence and everyday living services. Their contribution level is based on an income and assets assessments.  

Clinical supports, like nursing care, are fully funded by the government. You cannot ask participants to contribute to these services.   

Learn more about participant contributions. 

Exiting the pathway 

Participants may exit the pathway when:  

  • they pass away 
  • they no longer wish to remain at home or can no longer remain at home 
  • their End-of-Life Pathway ends. 

If a participant requires Support at Home ongoing services following the End-of-Life Pathway:  

  • an urgent Support Plan Review can be completed to assess their ongoing support needs 
  • where appropriate, the participant can transition to a Support at Home ongoing services classification. 

If a participant passes away, their family, carers or registered supporters should notify you, ideally in writing. You should then notify Services Australia. You will have 60 days to finalise any claims with Services Australia. 

Resources

You may find these resources helpful:  

If you offer End-of-Life Pathway services to older Aboriginal or Torres Strait Islander people, you may find these resources helpful:  

You may also choose to provide the Guide to End-of-Life Pathway booklet to older people who want to access the pathway and their families, friends, or carers.

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