STAYING WELL AT HOME: HOW HOUSEBOUND RUGBY RESIDENTS ARE BENEFITTING FROM PREVENTATIVE HEALTH AND CARE SUPPORT

The situation

Many patients in Rugby are housebound, meaning they rarely leave their homes due to health or mobility issues. This can make it difficult for them to access healthcare, information and support services. These patients range in age from their 40s to over 100, with most in their 70s, 80s, and 90s.

Many have long-term health conditions such as cancer, Chronic Obstructive Pulmonary Disease (COPD), mobility challenges, dementia, or limited family support. Traditionally, housebound patients receive care only when they are unwell, often missing proactive support that could prevent hospital visits or deterioration in health.

Being housebound often leads to feelings of isolation, unmet needs, and challenges in managing health conditions. Recognising this, Rugby Primary Care Network (PCN), which includes 12 GP practices in the Rugby area, identified a need for a structured approach that ensures patients receive personalised care while remaining in the comfort of their own homes.

What we did

In 2025, an enhanced practice nurse and a care coordinator joined the PCN to focus on proactive, holistic care for housebound patients. Between them, the team visits patients in their own home and spends time listening, talking and understanding each person’s health, lifestyle and social situation. The visits often last up to an hour, giving patients the space to share what matters most to them so a personalised care plan can be developed. 

During visits, patients’ have their key health indicators checked like blood pressure, pulse, temperature, breathing rate and medications, and they can be connected with other support services such as physiotherapy, occupational therapy, social prescribing, mental health support or social care when needed. 

After the visits, the care coordinator will conduct further review and follow ups with patients to ensure they have everything they need and are signposted to additional services as needed. 

Family members and carers are also supported to help them feel confident and supported in managing care at home. The focus is on preventative care to help reduce the risk of hospital admissions.

The service is continually evolving. Over time, care plans have been refined, data tracking has been improved, and additional health reviews such as dementia screenings and mini cancer care checks have been introduced. An information leaflet has also been developed for patients and families, explaining the service and what to expect from the visits.

The outcomes

Patients feel supported, reassured, and less isolated. They value the regular visits as a chance to discuss their health and wellbeing. Families and carers also benefit, gaining guidance and peace of mind about how to manage care at home. The preventative, proactive approach helps reduce hospital admissions for patients with long-term conditions, and strengthens connections between patients, families and other healthcare providers. 

Talking about the service, Sarah Kay, Enhanced Practice Nurse, said:

“The service is still developing, but even in its early stages, it has made a real difference to the lives of housebound patients and their families. 

“By taking the time to listen and step in early, we can offer tailored support, reassurance, and help people access the care they need at home. In turn, this means fewer hospital visits, less loneliness, and patients feeling safer, supported, and treated with dignity through coordinated care.”

Patient Case Study: How a patient is benefiting from Rugby PCN’s Housebound Service 

This case study shares the experience of a family carer supporting her elderly father at home, and how the coordinated housebound support service has helped improve comfort, communication, and peace of mind during a challenging period.

The situation

Maria cares for her father, who is nearly 95 years old and living at home with significant mobility difficulties and complex health needs. Due to weakness in his legs, arthritis, and ongoing infections, everyday activities had become increasingly difficult for him.

Simple movements, such as walking from his chair to his bed, could take several minutes, and most of his daily life was centred in one room. Over time, Maria began to feel overwhelmed trying to coordinate care, equipment, and medical support.

She said:

“I didn’t know who to contact. We’d been waiting months for equipment. and I just felt alone trying to manage everything.”

Challenges faced

Before receiving additional support, the family experienced several difficulties including long waits for essential equipment, uncertainty about who to contact for help, physical strain on carers supporting transfers and personal care, managing continence needs and increased laundry, concerns about comfort and safety at home and emotional stress and worry as her father’s health declined. 

Maria’s father was becoming increasingly uncomfortable sitting and sleeping, and existing equipment was no longer suitable for his needs.

How the Housebound service has helped

Maria received a call offering an annual wellbeing check for her father. During a home visit, two members of the housebound team spent time listening to both Maria and her father.

Rather than focusing only on clinical questions, the team encouraged open conversation and identified concerns through discussion.

Maria said:

“They were so easy to talk to. They just let me talk and picked up on things I didn’t even realise were important.”

Importantly, Maria’s father was included in conversations, helping him feel respected and involved in decisions about his care.

What changed

Following the assessment, practical support was quickly put in place.

Equipment was delivered including:

• A specialist pressure-relief cushion 
• A suitable medical mattress 
• Continence products were reviewed and adjusted 
• A hospital bed was installed to improve safety and comfort 

These changes improved comfort for Maria’s father and reduced physical strain on care staff.

Maria added:

“Dad is now comfortable in his bed, and the carers can support him safely.”

“One of the biggest improvements was having a single point of contact, instead of navigating multiple services. I could call one number and be connected to the right professional.

“Knowing someone would be at the end of the phone made everything so much easier. Talking to the nurses helped me know I was doing everything possible to keep him comfortable.”

Overall, the support service helped achieve improved comfort and dignity for the patient, faster access to equipment and clinical support, reduced stress for the family carer, better coordination between services, and it gave Maria increased confidence in managing her father’s care at home. 

For more information about the service and Rugby PCN, click here.