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Self care and patient carer information

The service does not discharge anyone as MS is a progressive disease.

If a patient moves out of the area, a referral to the Local MS Nurse and Neurologist is made, with copies of all relevant documentation copying all this also to the new GP.

The Nurse is able to refer to other professionals for ongoing treatment and advice. If the referral is urgent then a telephone referral is made which is followed by a letter

Literature:

  • The MS Trust and the MS Society (national and local) provide an excellent resource of literature which is available for patients. On diagnosis, the service provides a pack of information from both society and trust covering "what is MS", work issues, and benefit advice, information for children and teenagers, MS Matters and a joining form for both the society and trust. Feedback from patients says this is an excellent resource.

Physio / education courses:

  • These run for 6 weeks covering a variety of education such as fatigue management and bladder symptoms.
  • These are running in Ross and Bromyard

Exercise:

  • Weekly MS exercises classes funded by the Local MS Society are held in Ledbury, Leominster Ross and Hereford, with potential to open another in Kington 

Education:

  • Annual information days for PWMS and people with an interest in MS.
  • Physio/education courses lasting 6 weeks, covering a variety of topics, from fatigue, bladder symptoms.
  • Teaching to Healthcare Professionals, GPs, Care Agencies, Nursing Homes

Relapse Management:

  • Patients who are relapsing may be triaged over the phone or in clinic. (Relapse is new or old symptoms which are lasting for 48 hours).
  • Once it is determined that the patient is relapsing after talking to other relevant professionals, GP etc then refer to Neurologists for Intravenous Methyl-Prednisolone (IVMP) 3 days in a row at the Fred Bulmer building as a day case.
  • 6 week follow up in clinic to review progress and to action referrals if needed.

Disease Modifying Therapies:

  • Referral to a neurologist, for consideration of treatment, DoH risk sharing scheme entry criteria
  • Once the decision is made for treatment, then the MS Nurse informs the patient of there drug choices, demonstrates the differing drugs and provides literature.
  • The drugs are ordered by the MS Nurse, via home delivery companies
  • Teaching of the injection technique is provided within the patient's home.
  • Monitoring of the drugs is done monthly for 2 months then 6 monthly, asking the patients GP's to monitor the blood picture.
  • Annual reviews are performed by the Neurologist also

Joint working with MS Society:

  • Weekly exercise classes within the HALO gyms, in Leominster, Ross, Ledbury and Hereford. Soon to be in Kington too. All funded through the Local MS Society
  • Carers befriending telephone support line
  • Equipment library of: exercise bikes, vibrating circulation boosters to be circulated around PWMS who require the equipment

© Wye valley NHS Trust 2017