Clinics GRP Nursing pathway
Time-limited nursing follow-up after hospital, illness or surgery, connected with rehabilitation when wounds, medicines, monitoring, mobility or confidence need coordinated attention.
Care can occur inClinic, inHome, inCommunity or inCare, subject to referral information, clinical fit, location or facility arrangements, equipment, accepted scope and nurse availability. Digital supports access and coordination rather than universal online treatment. This is not an emergency or 24-hour response service.
Who it may suit
What nursing can include
The first visit confirms what can be safely delivered, what needs monitoring and who must be informed if the clinical picture changes.
Select a step to explore the detail.
Review the available discharge information, current care plan, medicines context and treating-team instructions.
Identify immediate nursing priorities, practical risks at home and any issue requiring medical review.
Agree a time-limited follow-up plan, communication responsibilities and rehabilitation handover where indicated.
Expected review points
Scope and boundaries
Call Triple Zero (000) for a life-threatening situation. Sudden or severe deterioration, heavy bleeding, acute obstruction, chest pain, severe breathlessness or new stroke-like symptoms require urgent medical assessment rather than a routine website enquiry.
Nurse allocation
Intake confirms the registration, competence and authorised scope required before allocating a nurse.
Communication
With consent, relevant findings and escalation can be communicated to family, GPs, hospitals, providers and other clinicians.
Funding and access
If eligible nursing is included in an approved Support at Home plan, a 0% participant contribution applies to that clinical service. The service still uses available programme funding and remains subject to the service agreement, registered-provider arrangements and accepted nursing scope.
Assessment-led nursing support for acute and chronic wounds, skin tears, pressure injuries and postoperative wound needs, with documented review and escalation when the clinical picture changes.
View pathwayNursing support for authorised medication administration, adherence, injections and clinically indicated observations, with communication to the relevant GP, pharmacist or provider.
View pathwayA structured older-person nursing assessment to identify current clinical priorities, risks, required follow-up, communication needs and an appropriate review plan.
View pathwaySystematic reviews support coordinated transitional care and discharge planning for older adults, including nurse-coordinated models. Effects vary and do not justify promising prevention of readmission or hospital-level care at home.
Clinical sources
How to read this evidence
Evidence guides care but does not establish that a service is suitable for every person or guarantee an outcome. Assessment, goals, health conditions, functional capacity, consent and identified risks shape individual care.
Reviewed by: Clinics GRP Clinical Review Team, Clinical review and governance
Last reviewed: 2026-08-15
Timing depends on the discharge plan, clinical priority, address, required information and nurse availability. Intake confirms whether the requested start can be safely supported.
Yes. One intake pathway can consider both nursing and rehabilitation when clinical follow-up, mobility, strength, balance or confidence need coordinated attention.
No. This is community nursing follow-up after discharge, not a hospital-substitution service. People requiring hospital-level care should use the treating hospital’s pathway.
Explore the questions behind nursing assessment, wound review, medicines support and recovery at home.
Explore nursing follow-up after hospital, from discharge information and medicines to wounds, mobility, coordination and review at home.
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Understand nursing observation and communication after prescription changes, with clear boundaries for prescribers, pharmacists and urgent care.
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When nursing and physiotherapy may need to coordinate around an older person’s priorities, and what makes a shared care plan useful.
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