How We Work with NHS Trusts and ICBs to Keep Complex Patients at Home

Hospitals save lives – but they are not always the best place for people to live long-term, especially those with complex and ongoing health needs. Many patients, families and clinicians want the same thing: safe, well-supported care at home, with the right clinical oversight and a clear plan if things change.

Making that happen takes real partnership.

At Aeon Nursing, we work closely with NHS Trusts, Integrated Care Boards (ICBs), discharge teams and Continuing Healthcare services to design and deliver nurse-led complex care at home. That might mean rapid step-down packages from hospital, reablement to prevent readmission, or long-term home-based support for adults and children with very high needs.

This article lifts the lid on what that partnership looks like in practice – for families, clinicians and commissioners.

Why Collaboration with the NHS Matters

People with complex needs often move through many parts of the system:

• Hospital wards and intensive care
• Community teams and outpatient clinics
• Social care and voluntary services

Without co-ordination, it’s easy for information to be lost, risks to be missed and families to feel forgotten.

Working in partnership means:

• Everyone is clear who is responsible for what
• Clinical decisions are shared and transparent
• The person and their family are not left to “hold it all together” alone

Our Role in the Patient Pathway

From Ward to Home

We are often involved before a person even leaves hospital. A typical pathway might include:

• Referral from a hospital team or CHC nurse
• Joint assessment with the ward team and family
• Home visit to assess the environment and discuss options
• Agreement on what’s needed for safe discharge

Step-Down, Reablement and Long-Term Care

Some packages are short-term and focused on reablement or preventing readmission. Others are designed as long-term, nurse-led complex care at home.

Whatever the length, the core goals remain:

• Safety
• Stability
• Quality of life

Working with Hospital Teams and Discharge Planners

We understand how pressured hospital discharge can be. To make things smoother we:

• Attend discharge planning meetings (in person or virtually)
• Provide clear information about what we can deliver and by when
• Help plan any training that families or support staff might need before discharge

We also liaise with hospital therapists, dietitians and specialist nurses so that goals and routines started on the ward can continue at home.

Partnering with ICBs and CHC Teams

Integrated Care Boards and Continuing Healthcare teams have to balance:

• Clinical safety
• Individual preferences
• Financial stewardship

Our job is to support that balance by:

• Providing detailed care plans with clear clinical rationales
• Giving accurate costing for different package options
• Reviewing packages regularly so funding reflects current needs

We see ourselves as part of the same system, not a separate “add-on”.

Clinical Governance and Safety at Home

Good governance is one of the biggest concerns for NHS partners – and rightly so.

To keep people safe at home we have:

• Nurse-led clinical oversight with clear lines of responsibility
• Policies and procedures aligned with national guidance
• Regular supervision and competency checks for staff
• Robust incident reporting, investigation and learning

We also work closely with community teams, GPs and out-of-hours services so that everyone knows how to escalate concerns.

Reducing Avoidable Hospital Admissions

For frail or high-risk patients, a well-structured home care package can prevent many avoidable admissions. Live-in or high-intensity complex care can:

• Spot early signs of deterioration
• Ensure medication, hydration and nutrition are well managed
• Act quickly on concerns, involving the right professionals at the right time

That benefits:

• Patients – who stay in familiar surroundings
• Families – who feel supported, not alone
• The NHS – which can focus hospital beds on people who truly need them

What This Means for Families and Referrers

For families, partnership working means you don’t have to co-ordinate everything yourself. There is a clear plan and a named team.

For clinicians and commissioners, it means:

• A provider that understands NHS pressures and processes
• Transparent communication and documentation
• A shared focus on safe, sustainable care at home

Need a home-based solution for a complex patient?

If you’re a family, clinician or commissioner exploring complex care at home, our clinical team can help you understand what’s realistic and how we would work alongside your NHS services.

To discuss a potential package or referral, contact info@aeonnursing.co.uk and ask to speak with our clinical team.

Important Information

This article is for general career information only and does not form part of any job offer or employment contract with Aeon Nursing. Roles, duties and benefits described are examples only and may vary by position, location and service needs. All employment is subject to Aeon Nursing’s usual recruitment procedures, professional registration requirements and safeguarding checks. For current vacancies and full terms, please contact our recruitment team or visit our careers page.

Author & Content Writer: Dr Naeem Aslam