Chronic kidney disease (CKD) is a major health and economic burden to the Australian community. It is estimated that around 2 million Australians have CKD, many of whom are undiagnosed and/or under-treated. Strategies which are likely to improve CKD care include increasing CKD awareness and education among patients and general practitioners (GPs), early detection and timely intervention. To address this issue, we have developed a CKD model of care targeted at patients with early CKD (stages 1-3). A renal medicine referral form is required for all new patients referred to our renal service by GPs. This provides: (1) information regarding CKD risk factors, urinary abnormalities (proteinuria, haematuria) and renal imaging, (2) the ability to triage and direct patients into the appropriate clinical setting, and (3) a mechanism for providing GP education. Appropriate patients are referred to a CKD clinic which is run by a clinical nurse consultant according to a defined clinical pathway (aligned with accepted local guidelines, such as CARI and National Heart Foundation) and in collaboration with a consultant nephrologist. Patients are also identified using a urinalysis screening program of outpatients who are at high risk of developing CKD (cardiology and diabetes clinics). Of the 480 patients who were screened in the first 12 months, 25% were found to have proteinuria > 30 mg/dL (57% of whom were followed up in the CKD clinic). Patient and GP education is critical and is facilitated using a CKD Action Plan which clearly outlines clinical issues, treatment targets and suggested interventions.