Multidisciplinary care is delivered by professionals from a range of disciplines who work together to deliver comprehensive care that addresses as many of the patient’s health needs as possible1. This can be delivered by a range of health professionals functioning as a team under one organisational umbrella or by professionals from a range of organisations, including private practice, brought together as a unique team. As a patient’s condition changes over time, the composition of the team may change to reflect the changing clinical and psychosocial needs of the patient1.
While we know that the multidisciplinary approach is best practice, we also know that how this is accessed may vary for each person due to availability of services in a person’s local area. In Australia, coordination of care can present challenges due to service boundaries, distance, funding and health sector accountability to different levels of government2.
People living with motor neurone disease are likely to need advice about mobility, communication, breathing, nutrition and getting community support for themselves and their families.
Evidence suggests that better support and advice is provided to people with MND when the healthcare professionals involved are knowledgeable about motor neurone disease and take a coordinated, multidisciplinary, team approach to your care6,7.
Importantly, how you manage some of your earlier symptoms can affect how other, later-developing, symptoms can be managed. Multidisciplinary care including specialist palliative care services, respiratory care and allied health professionals can improve survival and outcomes for people with MND8.
Multidisciplinary care can provide people living with motor neurone disease:
Ideally, you will have a direct link to one member of the team, usually referred to as a key worker or support coordinator. This person can advise you about regular review of symptoms and coordinate your care.
Key workers maintain regular contact with you and helps coordinate effective and timely review, discussion and support as your needs change. They are central in liaising with your team members to ensure your needs are met.
Who is your key worker is, will vary from service to service and depends on:
Community service providers coordinate and provide general household assistance, emotional support, care and companionship to people in their homes.
Dietitians provide dietary and nutritional advice including advice about modified meals and hydration.
A GP is a doctor providing general medical care. They are often your first point of contact and liaise with the neurologist and other professionals involved in your care.
MND association advisors help people with MND connect to the services they need. MND advisors offer ongoing support to families and service providers as questions arise or needs change.
The neurologist is a doctor who specialises in disorders of the nervous system. The neurologist coordinates the tests you need for diagnosis and monitors disease progression and management of symptoms.
Nurses are involved in ongoing care and care coordination, often for people in their own homes. Specialised nurses usually work in MND clinics and are experts in MND symptom management.
An occupational therapist (OT) helps to maintain mobility, function and independence. OTs provide advice about home modification, different ways of performing tasks and specialised equipment.
An orthotist provides artificial or mechanical aids, such as braces, to protect or assist affected joints or muscles and help optimise function for people with MND. It is recommended that an orthotist be consulted early to provide prompt access to orthotics.
The palliative care team specialises in interventions that can improve quality of life for people with life limiting conditions. Palliative care services may provide emotional support for people living with MND and can assist you to plan your future care.
A physiotherapist helps you maintain independence and mobility and can show your family or carer how to safely support your movement. Respiratory physiotherapists assist with breathing, coughing and non-invasive ventilation.
The respiratory specialist is a doctor who specialises in disorders of the lungs and breathing. They provide information and advice about breathing and timely access to non-invasive ventilation.
A social worker, psychologist or accredited counsellor provide psychological and emotional support for people living with MND. In addition, a social worker can provide information about community services and may assist you with accommodation, legal, financial and other issues.
A speech pathologist helps with communication and swallowing difficulties. They can advise about communication aids and devices, swallowing techniques and food consistency.
Support coordinators assist people who are diagnosed with MND when aged 64 or younger and who have an NDIS plan that includes support coordination. They may be employed by a MND association or by another organisation. The coordinators assist people to enact their NDIS plan and find suitable local services.
For more information about multidisciplinary care contact your local MND association via the MND Info Line on 1800 777 175.