Nursing in the Community


Derbyshire Community Health Services NHS Foundation Trust: Dementia Palliative Care Team

The team’s main aim was to improve care for people in Derbyshire who were living and dying with dementia, and had mental and physical health needs. Focused on helping them to remain at home, the service proved valuable in meeting patients’ palliative and advanced care planning needs, and in supporting their families.

Quantitative and qualitative analysis indicated that patients’ healthcare usage levels fell significantly after the first contact with the team, a reduction in non- elective inpatient spells totalled £367,000, and positive reviews were received from all involved with the team. The now substantive service continues to be a huge success, with recognition at a national level.


Bolton NHS Foundation Trust: Bringing care home with our intravenous nursing team

An initiative was rolled out so patients needing certain intravenous antibiotics could use a pump at home. The device was set up by a specialist nurse, negating the need for an inpatient stay. This tripled the number of patients who were treated.

Cheshire and Wirral Partnership NHS Foundation Trust: A needs- led mental health community rehabilitation team: working as part of a whole system

The project aimed to give multidisciplinary rehabilitation to people with complex mental health difculties in the community, instead of in hospital settings or out-of-area (OOA) placements. It led to bed days and OOA admissions being cut and financial savings being made.

Compton Care: The development of a dynamic and highly responsive community palliative nursing team

Changes were made to the company’s care model to improve patient access to end-of-life regimens. By investing in more non-medical prescribers and setting up a nurse-led multidisciplinary team, community palliative services supported patients to receive timely interventions and remain at home.

Countess of Chester Hospital NHS Foundation Trust: Urgent community response: virtual ward and care home teams enable people to stay at home

An SBAR (situation, background, assessment, recommendation) referral tool was adapted for use in four care homes to treat out of hospital. Emergency admissions fell and the scheme was rolled out to each care home in West Cheshire.

East Lancashire Hospitals NHS Trust: Improvements in the provision of end-of-life care: district nursing

Very few patients on the district nursing caseload died with an individual plan of care (IPOC) in place. A bespoke community IPOC was developed and an End-of-Life Care Champions group set up. Use of the IPOC increased by 54%.

East London NHS Foundation Trust: Tower Hamlets advance care planning team

Nurses were recruited to a team to help district nurses identify patients on their caseloads who might be nearing the end of life, so conversations around advance care planning could be had and holistic personalised care plans developed. Data showed that objectives were achieved.

Lloyds Pharmacy Clinical Homecare: Reducing the cancer backlog through efective partnerships

The company formed a partnership with numerous trusts across the UK and developed subcutaneous pharmacy clinics and infusion services to deliver high-risk cancer treatments closer to home. The initiative freed up more than 10,000 hours’ chair time in hospital.

Shropshire Community Health NHS Trust: Named nurse in community nursing

A new model of care was rolled out in the community nursing service so patients had a named nurse responsible for their assessments, care plans and reviews.
Serious incidents and complaints fell, patient feedback was positive and staf job satisfaction rose, boosting retention.

Southern Health NHS Foundation Trust: Diabetes team hard-to-reach project

People living with diabetes in a care or learning disability home were missing annual diabetes reviews. This project aimed to upskill patients and carers to improve diabetes management and reduce diabetes-related complications and hospital admissions. In total, 49 hospital admissions were prevented.

Surrey Downs Health and Care: Transforming the digital processes between GPs and primary care via EMIS system

Antiquated ways of accessing GP appointments and specialties working in silos resulted in delays in patient referrals received in community services. Aligning the referral process to EMIS led to improved inter-specialty communication and collaboration, and fewer delays.

Tees, Esk and Wear Valleys NHS Foundation Trust: REACH (Reducing Exclusion for Adults with Complex Housing needs) team

By linking with homeless services, the team aims to house those living on the street so interventions around their mental health and substance misuse needs can be implemented. Tens of individuals were housed and had their health needs assessed, and contact with crisis mental health services decreased.