This article explores the development of an ambulatory community service that demonstrates multidisciplinary working to meet the diverse needs of frail older people and their carers. The service comprises advanced nurse practitioners, a pharmacist, a community navigator, consultants, occupational therapists, physiotherapists, a nurse, rehabilitation assistants, a healthcare assistant and an administrator. This multidisciplinary team (MDT) serves adults with complex medical and rehabilitation needs who are being discharged from hospital, staying in bedded rehabilitation units or living at home by offering assessments, investigations and rehabilitation, where appropriate closer to home.

The aims of the service are to: keep people well, prevent unplanned hospital admissions, promote health and well-being, reduce the risk of falls, enable independent living and provide rehabilitation. Personalised care plans are developed with patients and their carers. Advanced nursing practice is demonstrated in assessment, investigation, diagnosis, management, referral and non-medical prescribing.

Development of this MDT is required to support and promote integrated, evidence-based work. Such development leads to integrated care across communities, and bridges gaps between patients and carers, GPs, home, residential and hospital-based services, and the voluntary, statutory and non-statutory sectors.