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Care coordination

Coordination of care is vital as many professionals and services are likely to be involved in the care of a person living with MND during the disease trajectory.
Regular team meetings ensure an optimal coordinated multidisciplinary team approach and the continuation of regular assessment and review throughout the course of the disease.

Hardiman 2007

Few healthy individuals know much about the intricacies of the health services. Accordingly, most people recently diagnosed with motor neurone disease do not know how to obtain experienced professional advice that is pertinent to their current and future needs.

Managing MND is not merely about providing an accurate diagnosis. It is about providing the appropriate amount of information about the condition at the appropriate time in a sensitive way.

Optimal management of MND requires a multidisciplinary team that operates in an integrated manner, so that patients do not have to focus on the process of sourcing appropriate health care, but rather on using health care in the way that best suits their individual requirements and those of their spouse, carer and extended family.

The pathways by which patients manage their progressive disability and access appropriate care and equipment may differ across health care systems. However the overriding aim is to provide a responsive service that enables the patient to reside in a safe environment, and to minimise the effects of their evolving disability on their activities of daily living. Ideally, the multidisciplinary team should comprise professionals who span both hospital and community-based services.

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