Page 92 - HHR-HNR 2.0

In a follow-up MDT meeting, the rehabilitation process is evaluated and rehabilitation goals are adjusted where necessary. In every MDT meeting, follow-up actions may be formulated for the team members. In the final meeting, the various assessment outcomes are discussed, treatment goals are evaluated, and it is determined whether the main goal has been reached and whether follow-up care is desirable. If necessary, a follow-up care pathway will be recommended and facilitated. Additionally, clinic appointments with the head and neck surgeon/oncologist and the rehabilitation specialist are made. Rehabilitation within one of the disciplines may in some cases be continued after the completion of the HNR programme. An overview of the guidelines for MDT meetings can be found in the table below.\u000DTable C: Guidelines for Multidisciplinary team (MDT) meeting head and neck rehabilitation programme\u000DStandard report MDT meeting Name of patient: Date of MDT meeting:\u000DGeneral impression\u000DShort discussion of possible discussion points/questions/uncertainties about the notes made in the preparation phase.\u000DFor follow-up discussions only: have the goals in the previous phase been reached? If not, why not?\u000DMost important rehabilitation needs\u000DWhat are the most important rehabilitation needs of the patient? Formulated in terms of participation level. In each meeting a top 3 of rehabilitation needs can be determined (the rehabilitation needs may therefore vary between the first and subsequent meetings).\u000DFunctional prognosis\u000DWhat does the team expect the patient will be able to achieve (across the different disciplines) in the coming rehabilitation phase and/or in future? This is essential for determining feasible goals, both for the team and for the rehabilitating patient.\u000DCore problem\u000DWhat does the team consider to be the most important problem for the patient in terms of rehabilitation? Why should the patient have (developed) these rehabilitation needs? Based on these questions, the core of the patient\u0027s problem is defined, as well as the goals/feasibility of rehabilitation.\u000DPrimary goals\u000DWhat is the single most important aim of rehabilitation? This may be an end goal, but may also be the main goal for the following six weeks, with a new main goal to be formulated in the next meeting.\u000DAction items team members\u000DContrary to rehabilitation goals, the action items included here are to be performed specifically by the allied health disciplines/physicians. Appointments may also be stated here.\u000DExpected treatment length\u000DHow long do we as a team expect that the rehabilitation of this patient will take?\u000D3.1.4 HNR team\u000DEach member of the team is responsible for their own prior and final assessments. Each team member furthermore draws up their own SMART goals with the patient, and explicates them in the MDT\u000D91\u000D