Review of clinic process and evaluation

1. Multiple Sclerosis Complex
Multidisciplinary Clinic
Sarah Roderick
Multiple Sclerosis Specialist Nurse
Huntingdonshire

2. Background
• Community Based MS Specialist Nurses – 1 WTE
• Sarah Roderick (0.6 WTE) Started in post in May 2014
• Ellie Garlick (0.4 WTE Jan – Sept 2016)
• 267 Patients on caseload - Average age of patients 56.2 years old
• Complex Needs – over 30% of caseload
• Newly Diagnosed, Relapsing Remitting, Secondary Progressive, End of life Care.
• 3 monthly contact – face to face / telephone review.
• .

3. High level
psychological
need
They require or would
benefit from an
Integrated MDT
Management Plan
Patient’s MS is in
transition from RRMS
into SPMS
Input from 3 or more
Neuro Health Care
Professionals
Patient has
complex
needs
Patient Inclusion Criteria for Attending Clinic

4. Neuro-
Physiotherapist
Speech & Language
Therapist
DieticianNeuro Occupational
Therapist
MS Specialist Nurse
Holistic Assessment
Individual Specialist Assessment
Issues of this approach
 Time Consuming
 Dis-jointed
 Repetition of information giving for patient
 Time out of work for multiple clinic / home visits for patients
 Lack of communication
 No access to high level psychological assessment in community
How Things Were
multiple referrals
Patient Presents with Complex Needs
– IAPT, Continence etc

5. Patient with complex needs
MS MDT Complex
Clinic
Neuro Physiotherapist
Neuro Occupational Therapist
Speech & Language Therapist Clinical Psychologist
MS Specialist Nurse
Rehabilitation Assistant
Disability & Benefits Advisor
Dietician
“I was very surprised by the opportunity to meet so many specialist people. It was very
positive”
Holistic Integrated MDT Management Plan
Seen by MS Specialist Nurse
Holistic Assessment

6. • 3 patients and family members are invited for 3-hour sessions at the
monthly clinic between 9 am – 2 pm. We phone beforehand to reduce
DNAs.
• On arrival patients review MS issues to identify priorities with the MSSN
- - feedback to the MDT – plan order / assessments
• The patient and family see MDT staff according to their needs and wishes.
• They evaluate their experience at the end of the clinic.
• The MDT meets to discuss Integrated MDT Management Plans, previous
clients, client feedback, future clinics and produces a clinic report for the
Patient and GP.
• Patients might then be offered: further clinic appointments or sessions
with one member of the MDT feeding back to the clinic as needed.
Clinic Process

7. MSSN
• Symptom Review
• EQUAL - QOL
Clinical Psychologist
• PHQ9 – Depression
• GAD7 - Anxiety
• Strategies for MS Progression
Rehab Assistant
• Functional test CHEDOKE
• Timed walk test
SALT
• Swallow Assessment
• Speech
Neuro OT
• MOCA – Cognitive
• Fatigue Strategies
Dietician
• MUST - Weight / Dietary
Disability and Benefits Advisor
• Benefits Advice
• Issues around Disability
Neuro PT
• Balance / Mobility
Holistic
Assessment

8. Evaluation
Increased MDT
working
communication
Shared goals.
Increased trust and
understanding of
each others roles
Shared
responsibility
Access to
Psychological and
neuropsychological
input
Patients and
Families see us as a
whole team
– reassuring that
we communicate
together
Cost Effective
Patient Satisfaction

9. Charlie Dorer - Neuro Physio
Cat Ford – Clinical Psychologist
Hilary Heath – Neuro OT
Penny Vaughan - SALT
Deb Fox – Neuro OT
Natalie Sutton – Neuro Physio
Sue Brenchley - Dietician
Janice Hudson – Rehab Assistant
Karen Jones – Admin Support
Judith Margolis – MS Society Benefits and Disability Advisor
Thanks for all team members who contributed to making this clinic a success
The Team