Further information for Referrers: Services One Two Three Four: offered: Inpatient MDT Assessment Inpatient MDT Assessment Outpatient assessment and Community Assessment and and Rehabilitation and recommendations Rehabilitation or Condition Condition management Management Patient profile Patients with a neurological Patients with a neurological LTC Patients with a neurological LTC, Patients with neurological LTC, LTC, who require intense, who require specialist inpatient currently in the community who who require intense, focused intervention, to regain intervention to manage their require a MDT or uni disciplinary intervention, to regain aspects of functional condition and any secondary review and recommendations for aspects of functional independence. needs complications. ongoing management. independence in their own home exceed what can be met To prevent acute admissions or and community or to manage through community or extended length of stay. This can include: Fatigue their condition and any outpatient services. management Programme, MS secondary complications in the Exercise Circuit group, MS Nurse community or within their own review. home Time Typically 6 to 8 weeks 6 to 8 weeks Maximum 6 sessions Typically 4-8 weeks Frame Service Provided Pre assessment Pre assessment. Specialist MDT assessment and Assessment. MDT input by specialist Specialist MDT assessment and recommendations. Uni or multi disciplinary input by clinicians based on intervention including: Provision of education, signposting specialist clinicians based on assessment findings. Postural, Pressure care and to available resources and liaison assessment findings. Individual rehabilitation spasticity/Contracture with involved agencies. Individual rehabilitation programme with long and management. Provision of a named contact and /condition management short term goals. Discharge Planning planned review service. programme with client focussed Discharge planning including Including home assessment, Provision of group: goals including: Postural, home assessment and transfer equipment/support services Fatigue Management Pressure care and of care sessions. recommendation, transfer of Programme spasticity/Contracture care sessions. MS Exercise Circuit group management . Uni disciplinary clinics MS Nurse clinic Inpatient Service Community/ outpatient service
Further information for Referrers: Services offered: One Inpatient MDT Assessment and Rehabilitation Two Inpatient MDT Assessment and Condition management Three Outpatient assessment and recommendations Four: Community Assessment and Rehabilitation or Condition Management Patient profile Patients with a neurological LTC, who require intense, focused intervention, to regain aspects of functional independence. needs exceed what can be met through community or outpatient services. Patients with a neurological LTC who require specialist inpatient intervention to manage their condition and any secondary complications. To prevent acute admissions or extended length of stay. Patients with a neurological LTC, currently in the community who require a MDT or uni disciplinary review and recommendations for ongoing management. This can include: Fatigue management Programme, MS Exercise Circuit group, MS Nurse review. Patients with neurological LTC, who require intense, intervention, to regain aspects of functional independence in their own home and community or to manage their condition and any secondary complications in the community or within their own home Time Frame Typically 6 to 8 weeks 6 to 8 weeks Maximum 6 sessions Typically 4-8 weeks Service Provided Pre assessment MDT input by specialist clinicians based on assessment findings. Individual rehabilitation programme with long and short term goals. Discharge planning including home assessment and transfer of care sessions. Pre assessment. Specialist MDT assessment and intervention including: Postural, Pressure care and spasticity/Contracture management. Discharge Planning Including home assessment, equipment/support services recommendation, transfer of care sessions. Specialist MDT assessment and recommendations. Provision of education, signposting to available resources and liaison with involved agencies. Provision of a named contact and planned review service. Provision of group: Fatigue Management Programme MS Exercise Circuit group Uni disciplinary clinics MS Nurse clinic Assessment. Uni or multi disciplinary input by specialist clinicians based on assessment findings. Individual rehabilitation /condition management programme with client focussed goals including: Postural, Pressure care and spasticity/Contracture management . Inpatient Service Community/ outpatient service