The Multimorbidity Model of Care (MMMoC) project was developed with the aim of improving outcomes for patients with CKD in South East London (SEL). As local data showed that demand for replacement therapy was expected to exceed capacity by 2036, all London ICBs received funding from the 3P renal transformation programme to improve outcomes for patients living with CKD within their local population. Recognising the multi-morbidity nature of CKD, SEL agreed a person centred, cardiovascular-renal-metabolic (CRM) approach, integrated across the care pathway to improve outcomes for our patients

• •Learnings from our model of care as an early adopter of an INT model, focused on multiple long term conditions (mLTC)
• •Our experience of integrating non clinical members of the team to support a proactive, holistic model that addresses the physical, mental, and social needs for better long-term health outcomes and quality of life.
• •Project outcomes (prevalence, use of evidence based therapies, impact on planned and unplanned hospital activity)
• •Patient and staff feedback
• •Top tips/pitfalls
• •Novel role of multi specialist pharmacists working in an integrated role