Skip to main content

Table 1 Different tasks of team members during intake and control visit.

From: Coordinated multidisciplinary care for ambulatory Huntington's disease patients. Evaluation of 18 months of implementation

Team member Tasks
Elderly care physician Assessment of the disease and the consequences for functional capacity (somatic, activities of daily living, social, psychological, communication)
Mini Mental State Exam
Neurological screening
Measurement of weight
Composition of the care plan and coordinating implementation
Medication prescription, crisis intervention
Information, support
Psychologist Visit at home with information on HD and the HD clinic
Psychological assessment on behavioural and communicative problems in the home situation
Cognitive assessment
Mood assessment
Experience investigation
Personal strong and weak points in relation to spouse, children, relatives
Ego-support, therapy
Supervision for patient and relatives
Speech and language therapist Swallow investigation
Speech and language processing assessment
Information, advice, therapy for swallowing, speech and language
Occupational therapist Assessment of manual dexterity and activities of daily living
Home visit with safety investigation
Observation of activity (showering, cooking, biking)
Advice and help or training with adjustments and aids
Therapy in organising and planning and executing activities
Social worker Life book
Assessment of carrying capacity of patient and caregiver(s)
Social support, advice and help in organising social network
Advice on financial problems
Case manager Responsible for organisation of care plan in home situation
First contact person for patient and caregivers
Linking pin to the multidisciplinary team members
Information and education to district nursing teams
Advice on regulations concerning care etc.