Care at Home

Executive Summary

Total Care at Home is a community-based complex care nursing service designed to close the high-risk gap between acute care and safe care at home. We partner with hospitals, specialist teams, discharge coordinators, general practitioners, and allied health providers to deliver rapid clinical assessments, risk-led care plans, patient and carer education, and ongoing complex nursing oversight in the home. Our core value proposition is straightforward: we reduce discharge delays, strengthen continuity of care, prevent avoidable deterioration, and lower avoidable readmissions by providing timely, structured, clinically robust support where people recover best—at home.

The service has been developed for real-world healthcare pressure points: delayed discharges due to unmet complexity, overwhelmed families, variable support worker confidence, and fragmented communication across providers. We address these constraints through a single coordinated model that combines clinical competence, practical education, and clear escalation pathways. Referrers receive rapid intake responses, assessment turnaround aligned to urgency, concise clinical communication, and documented risk-management actions that can be implemented immediately.

Our strategic goal is to become the trusted external complex-care extension for hospitals and GP practices across metropolitan and regional catchments, supporting safer transitions, better patient experience, and measurable system efficiencies.

The Problem We Solve for Hospitals and GP Clinics

Hospitals face recurring bottlenecks when patients are medically fit but not practically safe for discharge. GP clinics and specialists then inherit complexity without always having immediate, scalable home-based clinical capacity to stabilize care. In this setting, referral handover can be delayed, care plans may be too generic for home realities, and early warning signs are often missed until avoidable deterioration occurs.

Total Care at Home solves this by operating as a rapid-response community clinical bridge. We provide timely in-home assessment, risk stratification, individualized care planning, and practical education for families and care staff. This creates safer transition from inpatient settings, clearer role boundaries across providers, and more reliable escalation when risk changes. The result is fewer preventable setbacks, less duplication, and stronger confidence for referrers who remain clinically accountable for ongoing care decisions.

Service Offering and Scope of Practice

Total Care at Home provides comprehensive complex nursing and care coordination support for patients transitioning from hospital or being managed in the community under GP and specialist oversight. Our service scope includes:

• Seizure management and seizure-safe support plans.
• Care plans, clinical documentation, and staff education.
• Client and family education.
• Epilepsy care and emergency response planning.
• PEG feeding support and enteral nutrition care.
• Wound care, pressure injury prevention, and management.
• Complex wound care, including VAC dressings.
• Neurocognitive and behaviour-related care planning (positive behaviour support approach).
• Psychosocial support with a practical harm minimisation framework.
• High-risk client support and risk management planning.
• Diabetes management and blood glucose monitoring support.
• Cardiovascular supports.
• Medication administration and medication management support.
• Catheter care and urinary management.
• Complex nursing support and care coordination.
• Continence assessments and continence care planning.
• Comprehensive, person-centred complex care plans.

The model is not episodic and transactional. It is structured and continuous. We commence with a high-quality assessment, establish individualized risk controls, deliver education early, and then adapt intervention intensity as clinical needs evolve. Education is delivered to the patient, family, and care workforce so that care consistency improves across all shifts and settings. Referrers receive clear written summaries and recommended next actions designed for immediate operational use, not abstract theory.

Target Referral Partners and Patient Cohorts

Our primary referral partners are hospital discharge teams, nurse unit managers, care coordinators, emergency department short-stay units, hospital-in-the-home teams, rehabilitation services, GP surgeries, chronic disease clinics, specialist outpatient practices, and allied health providers managing complex community cases.

Our primary referral partners are hospital discharge teams, nurse unit managers, care coordinators, emergency department short-stay units, hospital-in-the-home teams, rehabilitation services, GP surgeries, chronic disease clinics, specialist outpatient practices, and allied health providers managing complex community cases.

Referral and Operational Model

Total Care at Home uses a streamlined referral pathway designed for clinical environments that do not have time for administrative friction. Referrals are accepted by phone or email from hospital teams, GPs, specialists, allied health providers, residential services, patients, and families. Intake captures patient identifiers, location, urgency, diagnosis and presenting issues, known risks, current supports, and referral goals.

Urgent high-risk cases are triaged for accelerated assessment, with a target first assessment window of 24 to 48 hours where clinically indicated. Standard referrals are typically assessed within 3 to 5 business days, dependent on geography and demand. Following assessment, referrers receive concise clinical documentation, risk summary, and a practical care plan with explicit escalation triggers. Education commences early and continues according to risk level and competency needs in the care environment. This operating rhythm directly supports discharge timelines and strengthens early post-discharge stability.

Clinical quality is governed through standardized assessment frameworks, risk-based care planning, and structured communication with referring teams. Every case is managed through an individualized safety lens that considers both clinical factors and environmental realities in the home. Escalation pathways are explicit and documented, with triggers for urgent review, referrer notification, and recommendation for higher-acuity intervention where required.

Our model is aligned to core principles of harm minimization, continuity, dignity, and informed choice. We prioritize clinically meaningful documentation, defensible decision-making, and consistency of education delivery. Governance includes periodic review of plan adherence, incident and near-miss trend analysis, review of outcome indicators, and continuous service improvement based on referral feedback and patient outcomes.

Clinical Governance, Quality, and Risk Management

Value Proposition to Hospitals and GP Surgeries For hospitals, Total Care at Home enables safer and faster discharge execution for complex patients by providing rapid community clinical capacity, practical risk controls, and immediate continuity planning. For GP surgeries, we provide an extension of primary care capability for patients who exceed standard practice resourcing but still require home-based stabilization and skilled nursing oversight. For both sectors, we reduce fragmentation by creating one accountable community interface for complex case implementation.

This is not framed as competition with existing services. It is a complementary specialist layer that protects acute capacity, supports primary care workflows, and improves patient and carer confidence during vulnerable transitions. In plain terms, we help your teams spend less time chasing avoidable deterioration and more time delivering planned care.

We propose a referral partnership model with hospitals and GP clinics built on responsiveness, transparency, and predictable communication standards. Each referrer receives a designated service contact, defined triage categories, expected response windows, and structured clinical updates. For higher-volume referrers, we offer regular case-review touchpoints to identify systemic barriers, streamline pathways, and reduce repeated handover inefficiencies.

Where appropriate, we can co-design referral criteria and escalation protocols with your clinical governance leads to align local workflows and risk tolerances. The aim is not just accepting referrals, but building a repeatable and trusted integrated pathway.

Partnership and Communication Framework

Performance is monitored using service and clinical indicators that matter to referrers and patients: time from referral to assessment, time from assessment to written plan delivery, percentage of urgent cases seen in target window, early escalation compliance, patient and carer education completion, and avoidable readmission trends in supported cohorts. We also track referrer satisfaction, communication timeliness, and continuity markers that demonstrate reduced fragmentation across care teams.

This allows hospitals and GP practices to evaluate partnership value with objective measures rather than anecdote. Over time, this evidence base supports stronger commissioning conversations and service expansion planning.

Outcomes and Performance Indicators

Our Total Care at Home is structured to support blended funding pathways including relevant government-funded streams and private arrangements, with transparent service definitions and clear intake triage. Financial sustainability is built on high-clinical-value interventions that reduce downstream system cost from failed transitions and avoidable acute representations. Growth is staged through referral partnership development, workforce scaling by demand zone, and disciplined governance to preserve clinical quality during expansion.

Commercial Model and Sustainability

The growth strategy is to establish depth before breadth: secure strong referral partnerships with priority hospitals and GP networks, demonstrate measurable outcomes, then scale geographically with a standardized operational and governance framework. Brand trust is built through clinical reliability, communication quality, and evidence of system benefit. Expansion into additional specialties and regions will be paced to maintain response-time integrity and care quality consistency.

Growth Strategy

Implementation Roadmap for Referral Partner Onboarding Initial implementation with a hospital or GP network begins with pathway alignment and a practical referral protocol. This is followed by direct liaison points, launch education for referrers, and activation of priority triage streams for high-risk discharge and complex community cases. The first ninety days focus on reliability, data capture, and communication quality. Quarterly review then evaluates outcomes, identifies bottlenecks, and confirms optimization actions.

Total Care at Home offers a clinically rigorous, operationally practical model for one of healthcare’s hardest problems: translating complex care plans into safe, consistent home reality. We are ready to partner with hospitals and GP surgeries that want fewer discharge delays, clearer risk management, and stronger continuity for patients with high-complexity needs. The service is designed to be responsive, accountable, and measurable from day one.

We invite your team to commence a referral partnership pilot with defined metrics, agreed communication standards, and immediate access to rapid assessment pathways for suitable patients.

Value Proposition to Hospitals and GP Surgeries

For hospitals, Total Care at Home enables safer and faster discharge execution for complex patients by providing rapid community clinical capacity, practical risk controls, and immediate continuity planning. For GP surgeries, we provide an extension of primary care capability for patients who exceed standard practice resourcing but still require home-based stabilization and skilled nursing oversight. For both sectors, we reduce fragmentation by creating one accountable community interface for complex case implementation.

This is not framed as competition with existing services. It is a complementary specialist layer that protects acute capacity, supports primary care workflows, and improves patient and carer confidence during vulnerable transitions. In plain terms, we help your teams spend less time chasing avoidable deterioration and more time delivering planned care.