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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

Ego-support

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.