Referral criteria and response time

• Patients should all be seen within 4 weeks of a referral
• Patients with a new diagnosis will be seen within 2 weeks of a referral
• Continued support from the service is offered
• All aspects of wellness, illness and social care benefits are assessed
• Prompt correct referrals to other health care professionals are actioned and followed up
• Patients have access to the most correct up-to-date information available
• Patients needing modifying treatments are assessed at an appropriated time
• Relapsing patients are triaged and treated within a 10 day timeframe

The model of delivery encompasses:

• Health promotion for people newly diagnosed with MS
• Management of people with MS at and after diagnosis
• Education of carers, health and social care staff
• Managing disease modifying medication
• Palliative care and management of people severely affected by MS

Once a Patient has been referred to the MS Nurse service either by telephone, letter, self, neurologist or GP: they are assessed according to there clinical need. Either in a clinic, within HHT, their work environment, case conference or a home visit.

The assessment encompasses a holistic approach, gaining an insight into the patient's symptomology, educational needs, financial / benefits, vocational needs and environmental factors.
 
Depending on the outcome of assessment, referrals may be made to other health care professionals.

Access is through: clinics, education, home visits, nursing homes, case conferences, telephone.

The MSSN work to a monthly outline of clinics and the rest of the work is fitted around this.

The clinics are throughout the county for ease of access:

• Bromyard Monthly
• Leominster alternate weeks
• Kington alternate weeks
• Ledbury monthly
• Ross monthly
• Gaol Street  weekly
• Hereford Hospital alternate weeks

The nurse service does not discharge anyone so follow up is always arranged at the time of appointment, the frequency of follow-up depend on the need, the usual time frames are 1, 3, 6, 9 or 12 monthly.

Referrals are accepted by: Telephone, however written information is also necessary to reinforce the referral, letter, e-Mail, face-to-face.

The referrals can be from any health care professional, self referral from a patient, or a referral from a family member as long as the person with MS has given them permission to make contact in the first place.

Appointments are made through either the MSSN or through the MSSN secretary. Or through the Choose and Book option.

The referrals are triaged by the MS Nurse and the person with MS will be seen in either a clinic or as a home visit.