Abstract
Background:
The nursing home population is expanding and presenting with increasing medical complexity. Specialist palliative care services collaborate with nursing homes to enhance quality of life for residents with advanced disease through timely identification and provision of palliative care. However, these efforts are often limited by workforce shortages, resource constraints, and a lack of clarity on how specialist palliative care can be effectively integrated into nursing home practice.
Aim:
To identify and map integrated models of specialist palliative care in nursing homes, describe their core components, and summarise reported evaluation outcomes.
Design:
A scoping review guided by Arksey and O’Malley’s framework was conducted.
Data sources:
Six databases (PubMed, Web of Science, Scopus, CINAHL, and Cochrane CENTRAL) were searched from inception to end October 2025. Studies describing SPC delivery integrated with routine nursing home care were included.
Results:
Twenty-three studies were included. Two integrated models were identified: (1) Specialist Consultation Services and (2) Palliative Case Management. Both involved interdisciplinary SPC teams supporting nursing home staff through shared expertise, staff training, and quality improvement initiatives. Specialist Consultation Services provided on-demand, resident-specific consultations, while Palliative Case Management adopted a proactive, team-based approach incorporating case conferences, and palliative care rounds to address residents’ ongoing needs.
Conclusion:
Two complementary models of integrated specialist palliative care in nursing homes were identified. Findings highlight shared and unique components that can inform development of modular, context-appropriate palliative care models tailored to nursing home capacities and resources.
Palliative care delivery is essential in the nursing home population.
Collaborating with specialist care providers has potential to increase timely access to appropriate palliative care.
Specific structures and components of integrated palliative care models involving external specialist palliative care providers have not been articulated.
Two integrated palliative care models were identified- Specialist consultation services and Palliative case management
Both aim to build palliative care capacity in nursing homes through shared specialist expertise and staff training.
Specialist consultation services provides on-demand physician input for symptom management and care planning.
Palliative case management adopts a proactive and multidisciplinary approach to address residents’ ongoing palliative care needs.
Findings can inform nursing home leadership and specialist palliative care providers in future design of integrated palliative care models for nursing homes. Mapping components in the care models can inform tailored implementation in nursing home palliative care service delivery.
Introduction
Globally, the nursing home population is rapidly increasing due to longer life expectancy and ageing demographics.1,2 The rising prevalence in chronic disease, polypharmacy, and functional impairments have intensified residents’ dependency on skilled nursing care.3,4 Nursing homes, also known as long-term care facilities, care homes, or residential aged care facilities, provide round the clock nursing care to individuals with complex health needs requiring assistance with activities of daily living. 5 Many residents live with life limiting conditions, frailty and cognitive impairment- and spend their final stages of their life in a nursing home. As this population grows, palliative care is essential to promote quality of life, adequate symptom management, and goal concordant care.
Despite this need, palliative care provision remains inconsistent and underutilised across the nursing home population.6–10 For instance, studies conducted in USA demonstrated that up to 70% of nursing home residents who were eligible for palliative care did not receive it, 9 while up to 30% residents do not receive adequate pain management at the end of life. 11 International evidence similarly demonstrates significant variation in palliative care organisation across nursing homes in Europe. 12 The COVID-19 pandemic further exposed critical gaps in policy guidance for end of life care in nursing homes, revealing insufficient provision of symptoms management, advance care planning, staff education, and bereavement care. 13
Within nursing homes, elements of generalist palliative care are provided, encompassing basic symptom management, psychosocial support, advanced care planning, and care coordination. 14 However, the quality and scope of care differs across countries and facilities, often constrained by staffing ratios, competency levels. Educational initiatives and clinical pathways such as the Gold Standards Framework, 15 Palliative Care for older people in Europe (PACE) Steps to Success Program and Nursing Homes End of Life care Program (NUHELP)16,17 have been introduced to enhance generalist capacity. Nevertheless, studies have demonstrated that education alone is insufficient to improve the quality of resident care.16,18,19
Persistent workforce and organisational barriers across nursing homes exist, such as high staff turnover, regulatory barriers, limited funding, and access to specialist palliative care services, medication and equipment. This underscores the need for structured, specialist-integrated models to promote timely and equitable palliative care delivery.20–22 In response, there has been growing interest in integrating specialist palliative care within nursing homes to address complex needs that extend beyond generalist capacity. Specialist palliative care models typically provide structured frameworks designed to organise care, integrating core components such as interdisciplinary teamwork, systematic assessments, advance care planning and ongoing co-management, and collaboration with nursing home providers.23,24 By leveraging the expertise of the specialist providers within a care model, nursing homes may enhance their capacity to address multiple aspects of clinical management, care planning, and providing psychosocial support to residents and their families.
Recent innovations such as telehealth outreach and shared care programmes have been sought in order to strengthen specialist palliative care delivery within the long-term care community. 25 While external specialists are increasingly involved as a consult service in lending their expertise, how such care is integrated, organised, and delivered is still poorly understood.26,27 Moreover, the delivery of specialist palliative care in nursing homes vary considerably, shaped by differences in health system structures, policy frameworks, and workforce capacity. 28 To address this variation, this review adopts an international perspective to map and describe how integrated models of specialist palliative care have been developed and implemented in nursing home settings worldwide. This synthesis identifies core components that may inform the adaptation of integrated palliative care approaches across diverse long-term care contexts. Findings aim to guide specialist palliative care providers and nursing home leaders in designing sustainable and context-specific care models which address the complex needs of residents at the end-of-life.
Methods
A scoping review guided by the Arksey and O’Malley framework 29 and subsequent refinements from Levac et al. 30 to identify integrated palliative care models in nursing homes, describe components of these care models and evaluation outcomes. The refinements incorporated iterative team discussions throughout study selection, data charting, and reporting, as well as the use of two independent reviewers to ensure consistency. The final consultation stage was not undertaken, as this review focussed on synthesising evidence from published literature. This review was reported according to PRISMA-ScR guidelines (Supplemental Appendix B). 31
Identification and description of the specialist palliative care models was guided by the empirically derived framework proposed by Firth et al., 24 which established key criteria for defining and comparing models of specialist palliative care. These criteria were grouped into components such as palliative care review processes, team organisation, initiation and modality of care delivery, and staff or organisational capability to inform data extraction and synthesis. This framework provided a structure for mapping how specialist palliative care is organised and integrated within nursing home settings.
Stage 1: Identifying the research question
The research question that guided the review was: What evidence exists on palliative care models that involve integrated working between nursing homes and specialist palliative care providers?
This review aims to: (1) identify and map integrated models of specialist palliative care in nursing homes, (2) describe the core components of these models, and (3) summarise reported evaluation outcomes.
Stage 2: Identify relevant studies
Inclusion and exclusion criteria
Articles were included if they described or evaluated palliative care services in nursing homes that involved the delivery of specialist palliative care by external providers in collaboration with nursing-home staff. Only full-text articles published in English were included (Table 1).
Inclusion and exclusion criteria.
Articles were excluded if they: (1) focussed solely on singular components of promoting palliative care for long-term care, such as staff training and advance care planning interventions, (2) described in-house palliative care teams directly employed under the nursing homes, (3) were not conducted in nursing homes, (4) not published in English language, (5) focussed on clinical care guidelines or standards in palliative care rather than models of care.
Search strategy
A comprehensive search strategy was developed and adapted for multiple electronic databases using Boolean operators, Medical Subject Headings (MeSH), and relevant free-text terms related to nursing homes, palliative care, and long-term care (Supplemental Appendix A). Key MeSH terms included ‘nursing homes’, ‘palliative care’, and ‘palliative medicine’. Five electronic databases were searched from inception to November 2025: PubMed, Web of Science, Scopus, CINAHL, Cochrane CENTRAL. Grey literature was searched, including targeted trial registries such as Clinicaltrials.gov and government and healthcare websites known to publish information on long-term care settings. Reference lists of eligible articles and literature review articles were screened to identify additional studies.
Stage 3: Study selection
A three-step screening process was undertaken to identify eligible articles. First, duplicate records were removed. Second, title and abstract screening was conducted by one researcher (ATJQ). Third, full texts were retrieved for studies that were potentially relevant after title and abstract screening. Two researchers (ATJQ and EWYL) independently reviewed all full-text articles and documented inclusion or exclusion decisions using Microsoft Excel. Discrepancies were resolved through discussion with a third reviewer (GYMJ) until consensus was reached.
Stage 4: Charting the data
A data extraction tool was developed and adapted based on components of specialist care models by Firth et al. 24 These components included referral criteria and timing, team composition and leadership, scope and mode of service delivery, and staff and organisational capability. Data were extracted independently by two reviewers (ATJQ and EWYL) and cross-checked for accuracy. Information was summarised into two tables: Table 2 presents the specialist palliative care components- palliative care review processes, team organisation, initiation of care, modality of delivery, and palliative care capacity building. Table 3 summarises key study characteristics, including author(s), country, publication year, study design, and reported evaluation outcomes (process, clinical, and healthcare utilisation).
Integrated specialist palliative care models in nursing homes.
ACP: advanced care plan; FTE: full-time equivalent; NP: nurse practitioner; NH: nursing home; PC: palliative care; RN: registered nurse.
Key features of the palliative care models identified of Specialist Consultation Services and Palliative Care Case management.
Several included publications reported different aspects of the same underlying study. To avoid duplication, publications were cross-checked for overlapping author lists, settings, participant populations, and intervention descriptions. Where multiple papers referred to the same dataset or care model, they were grouped and treated as a single distinct study.
The data extraction table was piloted on a subset of studies to ensure clarity and consistency. Table headings and extraction domains were refined through iterative discussions among co-authors with expertise in palliative care. The final components were developed through consensus discussions with expert clinicians and palliative care researchers on the team.
Stage 5: Reporting the data
Extracted data were narratively synthesised to provide a descriptive summary of the evidence. Studies were first grouped according to the type of integrated palliative-care model reported. Within each group, findings were summarised to identify recurrent structures and processes, including approaches to identification of palliative care needs, referral mechanisms, specialist multidisciplinary involvement, modalities of service delivery, and workforce capacity-building strategies.
Results
A total of 9793 articles were retrieved. 5884 duplicates were removed. After title and abstract screening, 223 full texts were reviewed. Finally, 22 unique studies were included, which were reported across 29 articles (Figure 1). Out of the 29 articles, 12 articles reported data from the same four underlying studies.32–35 Four articles were qualitative evaluations of the palliative care model and explored factors influencing implementation from nursing home staff and stakeholder perspective.36–39
PRISMA flow diagram.
Study characteristics
The 23 studies reported across 29 articles were conducted in Australia (n = 9), USA (n = 7), United Kingdom (n = 4), Singapore (n = 2), and Taiwan (n = 1). Out of 29 articles, five were randomised controlled trials, three employed quasi-experimental design, two utilised mixed methods approaches and two were pilot or feasibility studies. Seven articles reported qualitative research, six were observational and cohort studies and one described a pragmatic implementation study. Other articles included an evaluation report (n = 1), quality improvement report (n = 1), and a case study (n = 1). In the included studies, nursing home-based nurses and physicians, and external multidisciplinary healthcare providers were involved. Namely, palliative care physicians, geriatricians, neurologists, psychiatrists, family physicians, nurse practitioners, and registered nurses with different job roles (district nurses, nurse coordinators, nurse consultants, specialist palliative care nurses; see Table 4 – study characteristics).
Characteristics and reported outcomes of included studies (publications reporting the same study are grouped together).
Two distinct integrated palliative care models were identified (Table 2): (1) Specialist consultation services (n = 3) and (2) Palliative case management (n = 18). Classification of studies were based on shared structural and functional features extracted according to the five predefined components adapted from Firth et al. 24 : palliative-care review processes, team organisation, initiation and modality of care delivery, and staff or organisational capacity building. Studies describing episodic, referral-based specialist input, typically involving physician-led consultations to address complex symptoms or goals of care discussions were categorised as Specialist consultation services. In contrast, studies reporting proactive and ongoing collaboration between nursing-home staff and specialist providers, characterised by multidisciplinary case discussions, anticipatory care planning, and embedded staff mentorship, were classified as Palliative case management. Where both episodic and ongoing support coexisted, models were categorised according to the predominant mode of service delivery described.
Components of specialist consultation services and Palliative case management
Each of the care models are explored by the five main components identified, encompassing: (1) elements of palliative care review; (2) team organisation; (3) initiation of palliative care service; (4) modality of palliative care delivery; and (5) palliative care capacity building. Table 2 presents the components of both care models as narrated below, while Table 3 summarises the key features of both care models.
Elements of palliative care review
Across both models, care provision involved consultations to identify and formalise palliative care plans, establish goals of care and providing advisory on clinical management of the resident. Specialist healthcare providers conducted comprehensive clinical assessment, using structured templates document goals of care and manage symptoms.41,42
While Specialist consultation services included individual patient-physician consultations, the Palliative case management model incorporated additional components such as multidisciplinary case discussions. Multidisciplinary case discussions were mostly performed by nurse practitioners and specialty palliative nurses, to discuss care plans, goals of care, complex symptom management, and conduct appropriate coordination of services such as hospice referrals.34,36,42,43,51–53 Bereavement support provided by nurses and psychologists was provided in three studies.51,55,61
A prominent feature of the Palliative case management model was routine rounding by palliative physicians, nurse practitioners and specialist palliative nurse. Monthly 60-min triage meetings, known as ‘Needs Rounds’, were conducted in Australia and the UK to identify and formulate care plans for residents who were at greatest risk of dying without an appropriate plan or had high symptom burden.33,35,37,39,44,47,49,59,62 Follow up actions included further case conferencing, advanced care planning, medication and symptom management, and identification of legal decision makers. These care plans were directly communicated with nursing home staff and nursing home physicians for further follow-up.
In two studies which describe Palliative case management, ad hoc specialist palliative reviews were also conducted when an acute change was detected in nursing home residents on assessment by nursing home staff.50,55 In Ho et al., 55 residents who presented with urgent clinical needs were uptriaged to specialist palliative care nurses via telemedicine modality for review.
Overall, Specialist consultation services centred on individualised, referral-based reviews, whereas Palliative case management adopted a more proactive and system-oriented approach involving regular multidisciplinary case reviews, anticipatory planning, and staff capacity building.
Team organisation
Seven out of 21 studies described the palliative care team organisation. The composition of teams in Specialist consultation services varied: Amadoru et al. 40 was helmed by a physician and had a multidisciplinary team of nurses, social workers, chaplains, and psychologists, 41 Morris and Galicia-Castillo 42 involved a specialist palliative physician and a chaplain, while in Comart et al., 41 the team comprised of a specialist palliative physician and nurse. 40 In Palliative case management, there were physician and nurse teams.33,49,50,54,55 Two other teams included allied health professionals and care workers such as social workers, chaplains and psychologists.41,48
Nine Palliative case management services were nurse-led. Nurses were based in specialist palliative care units,55,57 in the community,51,58 or were independent nurse consultants.35,52 Service commitment ranged from 1 h a month, 47 1 day a month, 56 or full-time for up to 2 years. 54 Some services introduced nursing support in phases.45,53 In Temkin-Greener et al., 45 the nurse practitioner conducted palliative care rounds with nursing home staff biweekly for 2 months. Subsequently, the nurse practitioner stopped rounding, but was available to the nursing home staff for guidance for 10 months. 45 Several studies described parallel development of in-house palliative care team to facilitate rounding and case management with the external palliative clinicians.32,45,46 Seven studies did not describe the extent of involvement of the healthcare team.
The organisational structure of Specialist consultation services centred on physician-led teams providing episodic input, whereas Palliative case management featured predominantly nurse-led teams offering longitudinal engagement and integration with nursing-home staff.
Initiation of palliative care service
Across both models, residents were enrolled in palliative care services either through requests from nursing home teams or via automatic triggers based on structured criteria. In Specialist consultation services, referrals were solely based on nursing home team assessment when the resident had complex palliative care needs or family-related challenges which affected care goals.41,42 For example, in Amadoru et al., 40 nursing staff contacted the Resident In Reach service during acute resident deterioration with the GP. Decision to transfer to hospital considered resident’s functional status, cognitive levels, quality of life and prognosis, probability of complications. 37 In one hospice-nursing home partnership, all residents identified under the criteria received a compulsory consultation with a hospice physician. 50
In Palliative case management, a combination of referral criteria was utilised, including multiple admissions or readmissions to an acute hospital setting within a time period,48,57,60 residents with terminal cancer, heart or liver disease, or advanced dementia,43,50,53 prognosis of less than 6 months or a year as assessed by the healthcare team using tools such as the ‘surprise question’,33,34,55,57,59 symptom exacerbation,33,47,53,60 or presence of complex family dynamics that may hinder goals of care. 33 Nursing home staff in two studies applied validated or standardised tools such as ‘Supportive and Palliative Care Indicators Tool’.59,62
Resident enrolment in Specialist consultation services was typically reactive and referral-driven, whereas Palliative case management incorporated proactive identification using structured criteria and validated screening tools applied by nursing-home staff.
Modality of palliative care delivery
All studies reported onsite delivery of palliative care. One Specialist consultation service provided additional off-site service via telephone, 37 while three Palliative case management incorporated telephone40,48 and videoconferencing services.49,55 Out of seven services, three services reported after-office hours service (after 6pm on weekdays, weekends, and public holidays), where nursing home staff could contact the on-call physicians or nurse practitioners via telephone, telehealth modality, and instant messaging platform.48,49,61 In Mitchell et al., 52 nurse practitioners were available after-hours to provide emergency prescriptions if required. Fourteen studies did not specify if they provided an after-office hours service.
Both models primarily delivered palliative care onsite; however, it seemed that Palliative case management more commonly extended support through telehealth and after-hours availability, whereas Specialist consultation services remained predominantly in-person and within office hours.
Palliative care capacity
Overall, out of 21 studies, 18 incorporated capacity building for nursing home staff through palliative care education. In two of three studies classified under Specialist consultation services, upskilling opportunities were provided through physician teaching and a formal palliative care course.41,42 Topics taught during the formal palliative care course spanned across equipment usage, pain assessment, symptom control, communication, providing bereavement care.
Under the Palliative case management model, more focus was placed on case-based education and coaching was provided by nurse practitioners when they conducted case discussions and bedside rounds (Needs Rounds) in three studies.33,35,44,45,47 On the job training and preceptorship was also carried out by nurse practitioners and specialty palliative nurses.41,55,58,59 In two studies, nursing staff underwent the nationally accredited, geriatric-specific End-of-Life Nursing Education Consortium (ELNEC) curricula,41,45 and some included disease-specific topics such as dementia care.50,54 Training was commonly delivered in short modules or in-service trainings across multiple occurrences to maximise participation.
Organisation-level quality improvement strategies in palliative care were also described, through meetings with nursing home staff and leadership.42,48,50 Comfort care advisory committees which included pastoral staff, food service staff, nursing, and other ancillary personnel were established to strategise and develop protocols for providing comfort care in the nursing homes. 50 In one study, regular team and safety meetings were held twice a month to review causes of hospital readmissions. 48
Capacity building was present across both models. Specialist consultation services delivered primarily structured, whereas Palliative case management incorporated continuous, case-based training and organisational quality-improvement initiatives.
Evaluation of integrated palliative care models in nursing homes
All studies evaluated their respective model of care using multiple outcome measures. These included healthcare utilisation, healthcare costs, quality of life measurements, clinical indicators of palliative care, and frequency of clinical assessment and advanced care planning.
Process outcomes
The care models were evaluated through surveys, interviews and focus groups with nursing home staff and leadership. Across three studies (five articles), increased self-efficacy, perceived capability in initiating palliative care and knowledge was reported.36,44,50,52,54 Key barriers to implementation were identified in the qualitative data. Concerns were raised about the financial and logistical implications of involving external specialists and procuring additional equipment. The absence of administrative support for external palliative-care teams, coupled with organisational disruptions such as leadership changes and high staff turnover, further hindered integration and long-term sustainability.35,38,39,45,51 The implementation process of specialist rounding was influenced broader systemic gaps including limited readiness for change, variation in staff palliative care knowledge and skills, the absence of formal protocols to identify residents requiring palliative care, and poor understanding of existing workflows prior to introducing new clinical tools.37,59 As a result, care process modification and upskilling were identified to be necessary for successful implementation. 37 Nursing home staff requested for extended engagement from specialist providers and project leaders during the care model implementation in models which were designed to provide staggered support.53,59,63
Clinical outcomes
Clinical outcomes reported included documentation of advance-care plans, preferred place of death, and changes in goals-of-care documentation.42,52,53,55,56 Improved quality of dying, care and symptom management were mentioned by nursing home staff in interviews.52,53 Specifically, Comart et al. 41 and Temkin-Greener et al. 32 reported reductions in symptom burden, including pain and depression, following palliative-care involvement. Evaluation of Needs Rounds further demonstrated significant improvement in quality of dying was observed, suggesting multidisciplinary case discussions can improve end-of-life care experiences. 44 Only one study reported quality of life outcomes. 43
Healthcare utilisation outcomes
Seventeen studies measured healthcare utilisation, including number and length of readmissions, hospital visits, and healthcare cost.34,41,45,47,48,52,54–56,61 While cost savings were achieved in two studies under Palliative case management,34,41,57 and one Specialist consultation service, 32 mixed evidence was presented regarding the reduction in emergency department visits. Patterns of palliative care service utilisation were also tracked through the number of referrals and activities such as frequency of healthcare provider visits,51,60 and clinical activities such as prescription and symptom reviews.43,50,52,53
Discussion
This scoping review highlighted two models of care- Specialist consultation services and Palliative case management. Both models had distinct, but overlapping service components. While specialist consultation services focussed on reviewing residents identified by nursing home staff to have palliative care needs, palliative case management included additional components such as multidisciplinary case discussions and a focus on palliative care capacity building at both staff and organisational-level.
Historically, specialist palliative care input in residential aged care was typically initiated through ad hoc referrals by general practitioners or facility staff when residents approached the end of life. Such referral pathways were regarded as routine clinical processes rather than formalised models of care, and thus rarely evaluated or reported in current literature. The articles describing Specialist consultation services identified in this review may reflect incremental efforts to improve access to palliative care in NHs through ongoing tailoring of palliative care services. However, the introduction of formalised components such as structured and proactive identification of residents for palliative care, multidisciplinary reviews and capacity building, have given rise to a more comprehensive model. These formalised components align more closely with the Palliative case management model, which may explain why a larger number of articles describing this model were identified in our review.
Within both care models, pre-defined and structured referral criteria were applied by nursing home staff to identify residents with palliative care needs. However, two studies describing Palliative case management indicated that referrals were informally made based on practitioner assessment, without the use of standardised tools.41,42 Additionally, one implementation barrier identified in the included studies was the lack of protocol to identify residents who required palliative care. Implementation of evidence-based screening tools and structured criteria is recommended to ensure that residents are identified in a timely manner and streamline limited specialist palliative care resources.64–67 Ultimately, nursing home staff who are highly involved in resident care and well-acquainted with residents’ clinical conditions should be adequately trained by specialist providers to utilise these tools and criteria.
In this review, nine services under Palliative case management were nurse-led. Nurse practitioners were most involved in delivering specialist palliative advice, care management and on-the-job mentorship. We observe the growing involvement of nurse practitioners in providing expertise across different aspects of clinical care in the long-term care community to enhance accessibility and timeliness of care.68,69 Specialist-trained nurses are well-positioned to act as liaisons to provide both clinical care and education to enhance staff competency in end-of-life care within a multidisciplinary palliative care team. 58 Tapping on the expertise of specialist-trained nurses and providing on-the-job training also contributes to staff upskilling and capability building on top of didactic learning. Due to the varying involvement of the specialist providers across the studies, it is crucial to establish the amount of support required to meet the nursing homes’ needs. Concurrently, articulating generalist palliative competencies and standards for nursing home staff may provide further clarity as to how the integrated care model complements nursing home care with specialist expertise.
Majority of the specialist palliative care services were delivered in-person with little to no mention of after-office hours services. Existing research shows that outside office hours, timely access to palliative care is limited. 70 This underscores the importance of anticipatory care planning, which is a core feature of palliative case-management models. Residents at risk of deterioration are identified early and care plans are collaboratively developed in advance. Such proactive identification and planning can help mitigate after-hours crises, support consistent decision making by on-call staff, and reduce unnecessary hospital transfers, thereby enhancing continuity and quality of end-of-life care within nursing homes.
In addition to anticipatory care planning through regular case discussions and the establishment of care plans, there has been growing recognition of the role of telehealth to improve NH access to specialist care, especially after the Covid-19 pandemic.71–74 The flexibility of virtual models allows involvement of multiple healthcare providers, increasing family involvement and provide symptom management advice. This proves valuable for development of afterhours services, which is fundamental to community palliative care provision 75 – a component found to be limited in our included studies. However, future research is required to develop best practices of using tele-palliative care and evaluate its effectiveness on resident outcomes.
Nursing home staff identified multiple barriers to implementing integrated palliative care models in nursing homes. Implementing a new model of care requires full commitment from organisational leadership, change management and flexibility of iteration. 76 Implementing the care model often involves routine workflow adjustments surface while new working relationships between specialist providers and nursing home staff are formed. Our studies reported key challenges such as high turnover and staffing issues which impeded integration of specialist palliative care,77,78 an issue uncommon in long-term care settings. 79 Additionally, due to structural, organisational and staffing heterogeneity across nursing homes, dedicated palliative care units and nurses with palliative care training are lacking. 28 Therefore, levels of readiness for palliative training capacity and delivery of palliative care often differ across nursing homes. Structured readiness assessment on the necessary resources, skills, and infrastructure required to support components described in this review 80 can help to identify service gaps and tailor support to each nursing home.
What this study adds?
Insights into key components such as proactive identification of resident needs and capacity building are crucial to inform integrated care organisation in nursing homes. This can guide strategic and modular approach of developing integrated palliative care models tailored to nursing home settings.
From a practice perspective, these findings provide a framework for nursing-home leaders and specialist palliative care providers to design modular, context-specific approaches to integration. As a one-size-fits-all model is unlikely to be feasible, NHs may adopt phased or tiered engagement with external specialist teams depending on their organisational readiness and workforce capacity. Standardising referral criteria, embedding readiness assessments to guide resource allocation, and defining generalist palliative-care competencies can ensure that integration aligns with each organisation’s capabilities. Empowering specialist-trained nurses as clinical mentors and educators can further enhance on-site palliative capacity. Incorporating telehealth and after-hours planning may strengthen access and continuity of care for residents with palliative care needs.
This review highlights the need to expand the evidence base on integrated palliative care models in nursing homes. Further research is warranted to determine the optimal balance of specialist involvement, the use of telehealth modalities, and measurable outcomes that reflect both resident wellbeing and system efficiency. Studies in this review were also heterogenous in design and measured varying outcomes, with limited details on the interventions themselves. As underreporting of interventions has been a barrier to evaluation of palliative care models, 81 tools such as the TiDier (Template for Intervention Description and Replication) must be utilised in care model descriptions for clarity and replicability of future integrated palliative care model interventions. Pragmatic trials and implementation science approaches should be utilised to evaluate the development and evaluation of novel models with specialist palliative care involvement and explore long-term patient and implementation outcomes.
Strengths and limitations
This review was conducted using a rigorous and transparent methodology, with an extensive and updated database search. However, several limitations should be noted. Firstly, as the review aimed to map the breadth of existing evidence on collaborative palliative care models, formal quality appraisal of included studies was not undertaken. Secondly, although a comprehensive search strategy was applied, some relevant studies may have been missed due to exclusion of non-English publications. Restricting inclusion to English language studies may have limited representation of specialist palliative services in non-English speaking regions (Asia, Europe, South America), where system-level variations could yield different approaches to collaboration and integration. Future reviews incorporating multilingual searches could capture a more global understanding of integrated palliative care models in nursing homes.
Conclusion
This review identified two predominant models of specialist palliative care in nursing homes: Specialist consultation services and Palliative case-management models. Both share the overarching goal of improving end-of-life care but differ in their level of proactivity and system integration. Consultation services provide structured specialist input for residents identified as requiring palliative review, whereas case-management models embed proactive needs identification and anticipatory care planning through regular multidisciplinary discussions. Continuous capacity building through implementation of structured palliative care tools and ongoing upskilling of nursing-home staff is essential to sustain these models over time. Reported outcomes indicate improvements in symptom management, staff confidence, and care coordination, although sustaining these benefits remains challenging. Overall, these findings demonstrate a shift from reactive, referral-based specialist involvement towards proactive, collaborative models of care. Future research should employ implementation-science approaches to evaluate how these models can be scaled, adapted, and sustained within diverse long-term-care systems.
Supplemental Material
sj-docx-1-pmj-10.1177_02692163261416286 – Supplemental material for Integrating specialist palliative care delivery in nursing homes: A scoping review
Supplemental material, sj-docx-1-pmj-10.1177_02692163261416286 for Integrating specialist palliative care delivery in nursing homes: A scoping review by Apphia Jia Qi Tan, Elizabeth Wen Yu Lee, Catherine J. Evans, Xuling Lin, Sarah Ee Fang Yong and Grace Meijuan Yang in Palliative Medicine
Supplemental Material
sj-docx-2-pmj-10.1177_02692163261416286 – Supplemental material for Integrating specialist palliative care delivery in nursing homes: A scoping review
Supplemental material, sj-docx-2-pmj-10.1177_02692163261416286 for Integrating specialist palliative care delivery in nursing homes: A scoping review by Apphia Jia Qi Tan, Elizabeth Wen Yu Lee, Catherine J. Evans, Xuling Lin, Sarah Ee Fang Yong and Grace Meijuan Yang in Palliative Medicine
Footnotes
Ethical considerations
Ethical approval was not sought for this review. Secondary data was based on publicly available literature and does not involve any primary data collection or human subject research.
Author contributions
ATJQ and GYMJ conceptualised and designed the review. ATJQ and EWYL conducted the literature search, screened articles, and extracted data. ATJQ drafted the manuscript. GYMJ, CE, SEFY, LXL critically reviewed and revised the manuscript for important intellectual content. All authors approved the final version of the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data availability statement
All data from this review is available in the supplementary material.
Supplemental material
Supplemental material for this article is available online.
References
Supplementary Material
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