The network is supported to deliver the transformation pilot through investment in 7 system-wide pilot roles to deliver complex case management and care coordination, MDT facilitation and network support.
The following individuals have been appointed:
- Regional epilepsy MDT coordinator – Amy Stone will be supporting the regional epilepsy MDT to ensure it is available to use by all regional consultants with the aim of helping to facilitate the distribution of specialised care to local hospitals to ensure that patients are receiving the best treatment.
- Myasthenia gravis CNS – Shelly Rodriguez will support patients from across the region by serving as a direct point of contact to provide education, support with new diagnosis and link them in with support groups, and also running her own follow-up clinics with stable myasthenia patients.
- FND Care Advisor – Alex Phillips will be working with those with FND to promote self-management skills, develop emergency care plans and also link patient care across multiple services.
- MND Care Advisor – Holly Van Ristell will be providing assessments of complex clinical situations in acute and community settings, provide education and establishing pathways that align to local service provision.
- Advanced MS Champion – Michelle Black will be conducting home visits to assess people living with advanced MS in their home environment and she will be coordinating care by working across teams and social care to re-engage patients with essential care.
- Parkinson’s Clinical Network Manager – Alison Leake will be setting up a new SWL & Surrey Parkinson’s network in order to facilitate integration of MDT teams across primary, secondary and community care for those living with Parkinson’s.
- Neurosciences Collaboration Manager – Bethan O’Donnell will be providing senior programme management and leadership to the pilot and wider SWL & Surrey network through enabling collaborative working across partner organisations.
Benefits of working across the region:
- Network approach, working across the system and between providers
- Single point of contact specialising in disease area – with expert knowledge
- Work collaboratively with responsible clinical teams
- Opportunity to provide care closer to home
- Early intervention and escalation to avoid unplanned admissions
- Timely support to manage long-term conditions
- Education to teams across the system
- Supports innovative practice as treatments and interventions develop