The growth of an ageing population in the UK means that patients with chronic and multiple disease are more common (Department of Health [DH], 2013). One of the most important challenges for the future of health care is how to improve quality of life for people living at home with long-term disease for ever-longer periods of time. Community nurses working to avoid hospital admission for their patients will be only too aware of the cycle of chronic disease management, exacerbation, hospital admission, discharge and yet further exacerbation.