As more people live with complex health needs, care is increasingly being delivered closer to home. This requires health and social care services to work together to provide coordinated, person-centred support within local communities.
Nurses and midwives play a key role in multidisciplinary teams through assessment, advice, referral and the safe delegation of healthcare interventions. Effective collaboration across professions, providers and agencies helps ensure the right care is delivered by the right person, at the right time and in the right place.
Delivering coordinated care also depends on a skilled, well-supported workforce that can respond safely and effectively to people’s needs.
Key message: Good outcomes depend on effective partnership working, safe delegation, and coordinated care that enables people to live well at home and in their communities.
Right Care
Right Care
Collaborative working enables people to be active partners in their care, ensuring support is tailored to their needs, preferences and goals. Nurses and midwives play a key role in coordinating care, assessing needs, managing risks and ensuring healthcare interventions are delivered by the most appropriate person with the right skills and competence.
By working closely with individuals, families and multidisciplinary teams, nurses and midwives help deliver safe, person-centred and coordinated care, while reducing duplication and improving outcomes.
Expected outcome: People receive personalised, evidence-based care that reflects what matters to them and is delivered safely, efficiently and without unnecessary duplication.
Right Person
Right Person
People supported in the community often receive care from a range of health and social care professionals, each contributing different skills and expertise. Nurses and midwives play a key role in ensuring healthcare needs are assessed, planned and delivered by the person with the appropriate knowledge, competence and authority.
Safe and effective care depends on staff having the necessary skills and training, alongside clear roles, communication pathways and escalation processes.
Expected outcome: People can be confident that their care is delivered, monitored and reviewed by the most appropriate and competent person, ensuring safe, effective and person-centred care.
Right Time
Right Time
People should receive the right healthcare intervention at the earliest appropriate opportunity to prevent deterioration, avoid unnecessary complications and achieve the best possible outcomes. Nurses and midwives play a key role in identifying changing needs, coordinating care and escalating concerns to ensure timely intervention.
Effective multidisciplinary working, with clear roles and communication pathways, helps ensure care is delivered when it is needed most.
Expected outcome: People receive timely assessment, treatment and support that prevents avoidable delays and maximises health outcomes.
Right Place
Right Place
Nurses and midwives help ensure people receive care in the most appropriate setting, balancing safety, clinical needs and personal preference. Through effective assessment and coordination, they support people to receive care as close to home as possible, while reducing unnecessary hospital or care home admissions.
Expected outcome: People receive care in a safe, appropriate and accessible setting that reflects their needs and preferences wherever possible.
For more information on how nurses can support coordination of care ‘Closer to Home’ go to Principle Activities for Coordination of Healthcare – (including Delegation) section