The Queen’s Institute of Community Nursing innovation projects: Complex Needs in Primary Care

Across the ten nurse led projects some of the overarching aims included:

Improving health outcomes for people with complex needs living in community settings such as care homes, prisons, supported living, and patients who are housebound.

Enhancing access to care whether through digital technology, improved pathways, proactive reviews, or single points of contact.

Empowering patients and carers to better understand and manage long‑term conditions.

Reducing inequalities in health, particularly for vulnerable groups such as older people, those with learning disabilities, or people with chronic conditions.

Preventing avoidable hospital admissions by shifting from reactive to proactive, person‑centred care.

Strengthening multidisciplinary collaboration to deliver seamless, consistent, coordinated support.

Building staff knowledge and confidence through education, training, and new resources.

The programme achieved several notable and far‑reaching outcomes. Many initiatives led to clear improvements in people’s health and wellbeing, with participants experiencing better clinical markers such as reduced HbA1c levels, improved blood pressure, greater respiratory stability and fewer infections.

In many cases, patients were able to remain safely in their own homes due to earlier intervention and more coordinated support.

A significant achievement shared across several projects was the prevention of avoidable hospital admissions. By identifying deterioration earlier, improving monitoring and acting proactively, teams were often able to prevent unnecessary A&E attendances and inpatient stays. Some projects even reported periods with no hospital admissions at all among their cohort, demonstrating the impact of timely, community‑based care.

Another major success was the strengthening of multidisciplinary working. Projects created stronger networks between GPs, community nurses, care homes, social care, voluntary organisations, ambulance services and specialist teams. This improved communication and enabled more consistent, joined‑up and responsive care.

Staff development was also a standout achievement. Training programmes in areas such as oral health, respiratory care, frailty, dementia, and long‑term conditions helped build staff confidence and skills. Staff reported feeling better equipped to support people with complex needs, and many gained new leadership, digital or project management experience.

The projects also empowered patients and carers in meaningful ways. Virtual wellbeing sessions, exercise groups, peer networks, accessible educational materials and personalised care plans helped people to better understand and manage their health. In several areas, increased engagement led to improved mental wellbeing, greater confidence and stronger social connections among participants.

Innovation was another hallmark of the programme. Many projects successfully implemented digital technologies, such as remote monitoring devices, virtual group platforms, hydration sensors, or integrated care planning tools. These innovations not only improved data quality and care efficiency but also opened new opportunities for engagement, particularly during pandemic restrictions.

The sustainability and legacy of these projects stand out as key achievements. Many initiatives have now become embedded into routine practice, adopted at strategic level, or expanded into wider programmes such as the Enhanced Health in Care Homes framework.

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