Table 5.
Delivery of the integrated MND plan through the primary care system.
| Level of care | Key care provider | Goals | Interventions |
|---|---|---|---|
| Community/households | • Health Counsellor | • Detection and home-based care and rehabilitation of severe MND | • Mental health assessments |
| • Service Users/families | • Increasing awareness | • Psychosocial stimulation (for infants) | |
| • Volunteers | • Strengthening social support and inclusion | • Detection and referral | |
| • Promoting adherence and recovery | • Psycho-education | ||
| • Facilitating social welfare benefits | |||
| • Adherence management | |||
| • Review of progress | |||
| • Self-help groups | |||
| Primary Health Centre and district general hospital | • Health counsellors | • Detection of common MNDs | • Mental health assessments |
| • Mental health | |||
| • Programme leaders | |||
| • Confirmation of diagnosis of severe MND | • Provision of appropriate medications | ||
| • Monitoring of individual case management plans for all MNDs | • Provision of psychological treatments and yoga | ||
| • Inpatient management of acute or severe MNDs | • Clinical assessments and case note reviews | ||
| • Brief hospital admissions, for inpatient management of emergencies: suicide attempt, acute psychosis, alcohol withdrawal, status epilepticus, etc. | |||
| Other community agencies, e.g. NGOs | • NGO workers | • Mental health promotion and prevention of MND | • Mental health promotion |
| • Service Users/families | • Promoting recovery and reintegration of people with MND | • Community-based rehabilitation | |
| • Volunteers | • Self-help groups | ||
| • Advocacy | |||
| • Daycare and residential care |
MND: mental and neurological disorder; NGO: non-governmental organization.