During 2007 - 2008 Top End Renal Services, Darwin NT focussed on improving patient management between the acute renal sector, chronic prevention and palliative care services to improve care outcomes for our patients.

2007 saw the appointment of the renal/palliative care liaison officer to improve the end of life wishes for our renal patients. Project targets were for Advanced Care Planning for all chronic kidney disease patients, renal replacement treatment choices before referral to renal services, congruent educational resources, returning to homelands to die as a priority for most Indigenous patients, and inclusion of palliative care nurses in weekly care management meetings already established in renal services.

2008 saw an 800% increase in nursing staff appointments for management of chronic kidney disease in the Top End. Formerly there was one CKD Nurse for 350 patients. The appointment of eight Public Health Nurses in the Chronic Disease Network focused case management responsibilities for chronic kidney disease patients in rural and remote regions. Workshops and numerous meetings resulted in referral pathways being established to renal dietetics and renal social work,palliative care and access to a nephrologist for remote clinics.

Commencement of weekly case conferences between acute renal services and chronic disease networks, include remote clinic nurses, aboriginal health workers, regional medical officers, nephrologists, the acute CKD nurse and the renal nurse manager. Palliative care involvement is also by referral from these case management meetings. Access to acute renal services is now available for all remote patients who do not come to town.