#6672 THE DEVELOPMENT OF A COMMUNITY-NEPHROLOGY, MULTI-DISCIPLINARY SERVICE

Abstract Background and Aims The Walsall Together clinical operational leads constructed a collaborative initiative between nephrology community services. Driven to provide multi-agency, patient-focused care. aim of the MDT service is identify optimally manage individuals with acute nephrological presentations secondary complications chronic kidney disease (CKD) at home, while maximally utilising outpatient services prevent hospital admissions. Method Nephrology teams, including rapid-response, complex-case management, enhanced-care frailty teams devised for either community-acquired injury (AKI) or CKD. can consist of; nephrologist, community-CKD nurse, member from each above pharmacist an coordinator. Patients are identified attendee's caseload, heart failure geriatrician patient cohort. A weekly meeting held on Microsoft Teams, this allows efficient working across large geographical area. coordinator essential performance MDT. They responsible for: organising meetings, producing minutes, requesting laboratory investigations (including urine album in creatinine ratio), chasing results finally ensuring that actions generated completed. independent prescriber immediately any medication changes. advanced practitioners band 7/above nurse prescribers. All staff perform home visits fully utilise ambulatory-care-unit medical assessment, urgent imaging intravenous electrolyte replacement. medical-day-case unit administration blood transfusions. access team iron therapy antibiotic therapy. Results Currently, actively managing over 60 patients. This excludes patients who have been successfully managed discharged service. multimorbid, cohort recurrent admissions appear benefited most. reduction and/or cessation noted, after introduction interventions easily monitor housebound, reduces number related Furthermore, by illness community, admitted acquired AKI. Finally, unfortunate event terminal, irreversible pathology, care planning referral palliative Conclusion collaboration has demonstrated multi-agency approach renal disease, result cooperative multi-speciality approach, led improved monitoring management housebound