Objective <p>To evaluate Programme IMPACT, a home-based palliative care initiative for terminally ill non-cancer patients with end-stage organ failure and severe frailty at the end-of-life, in achieving palliative outcomes, honouring end-of-life care preferences, and reducing acute healthcare utilisation.</p> Methods <p>Patients with non-cancer diagnoses, prognosis of ≤ 6&#xa0;months, palliative goals of care, and preference for home as a place of care or death were enrolled between October 2017 and December 2021. First, we employed a single-arm prospective cohort design to assess symptom control and concordance between preferences and delivered care. Second, we compared healthcare utilisation, costs and place of death between programme decedents and non-cancer controls without palliative care identified retrospectively. Utilisation was analysed with Poisson regression, costs with generalised linear models (gamma log link), and logistic regression for home deaths, adjusting for baseline confounders.</p> Results <p>A total of 387 patients were enrolled in the programme. Patients experienced significant clinical benefit, with mean symptom scores improving by 2.5 points on the Edmonton Symptom Assessment Scale. Concordance between preferences and outcomes exceeded 94% for CPR status and medical treatments and 89% for place of death. Compared with controls, programme decedents incurred significantly lower utilisation and costs: admissions and length of stay (Rate Ratio [RR]: 0.65–0.85, <i>p</i> &lt; 0.005), admission-related and total costs (Mean Ratio [MR]: 0.56–0.75, <i>p</i> &lt; 0.001), and ED visits and costs (RR &amp; MR: 0.69–0.81, <i>p</i> &lt; 0.008). They were also 16.6 times more likely to die at home (95% CI: 10.2–27.0; <i>p</i> &lt; 0.001).</p> Conclusion <p>Home-based palliative care improves symptom control, aligns care with preferences, and reduces acute hospital use and costs among this population.</p>