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Chapter 3 Treatment planning\u000D3.1 Rehabilitation pathways\u000D3.1.1 New applications\u000DIdentification of a possible rehabilitation problem will primarily be the responsibility of the head and neck surgeon/oncologist, radiotherapist and/or oncology nurse. Patients may also, however, be referred by other members of the rehabilitation team, through other cancer centres, or by presenting themselves. The possible referral of the latter patients is also the responsibility of the head and neck surgeon/oncologist and/or the radiotherapist. A specialised head and neck oncology nurse/case manager establishes in a conversation with the patient and by using questionnaires (in line with the national guideline oncological rehabilitation) whether a rehabilitation need exists, and will, where necessary, refer the patient for monodisciplinary allied health care or for multidisciplinary rehabilitation. If there are medical grounds for multidisciplinary rehabilitation, intake with a rehabilitation specialist will take place within 14 days. Based on his/her expertise, the rehabilitation specialist assesses whether the patient is eligible for participation in a rehabilitation programme, and gathers the necessary medical information. When an external patient applies for rehabilitation, they will first be seen by the head and neck surgeon/oncologist to rule out potential interfering medical problems first.\u000D3.1.2 Intake with the rehabilitation physician\u000DThe rehabilitation specialist talks to the patient to establish the different rehabilitation needs, determines which treatment modules could be employed, and refers on to the relevant allied health professional disciplines. Depending on the rehabilitation modules selected, assessments are made before the start of treatment (see rehabilitation modules in Appendix 1E and the checklist for measurement tools in Appendix 2E). At the end of the intake phase, the core problem and rehabilitation needs of the patient are formulated in a multidisciplinary meeting, and several SMART rehabilitation goals will have been established together with the patient. The rehabilitation programme consists mainly of tailored treatments with tailored goals. If necessary, group treatments are offered too (see paragraph 2.4, page 91, for an explication of the SMART methodology). The rehabilitation specialist together with the patient subsequently defines the core problem to be addressed in rehabilitation, the expected length and frequency of the treatment and the various disciplines to be involved.\u000D3.1.3 Multidisciplinary HNR team meeting\u000DDuring a weekly Multidisciplinary Team (MDT) meeting patients, which is chaired by the rehabilitation specialist, a maximum of 10 patients on the programme are reviewed. Depending on the length of the tailored HNR programme patients are discussed several times at the MDT meeting, i.e. at the start of their rehabilitation, after each team member has formulated rehabilitation goals within their discipline, during rehabilitation and at completion of the HNR programme. The meetings are structured according to the multidisciplinary team meeting guidelines that are common usage in rehabilitative care (see Table C). At the first MDT meeting, the general impression, primary rehabilitation needs, functional prognosis, core problem, main goals and SMART goals of each patient are reviewed. Furthermore, an estimate is made of the expected length of rehabilitation.\u000D90\u000D