Table 1.

Different tasks of team members during intake and control visit.

Team member	Tasks
Elderly care physician	Assessment of the disease and the consequences for functional capacity (somatic, activities of daily living, social, psychological, communication) Mini Mental State Exam Neurological screening Measurement of weight Composition of the care plan and coordinating implementation Medication prescription, crisis intervention Information, support
Psychologist	Visit at home with information on HD and the HD clinic Psychological assessment on behavioural and communicative problems in the home situation Cognitive assessment Mood assessment Experience investigation Personal strong and weak points in relation to spouse, children, relatives Ego-support, therapy Supervision for patient and relatives
Speech and language therapist	Swallow investigation Speech and language processing assessment Information, advice, therapy for swallowing, speech and language
Occupational therapist	Assessment of manual dexterity and activities of daily living Home visit with safety investigation Observation of activity (showering, cooking, biking) Advice and help or training with adjustments and aids Therapy in organising and planning and executing activities
Social worker	Life book Assessment of carrying capacity of patient and caregiver(s) Social support, advice and help in organising social network Advice on financial problems Ego-support
Case manager	Responsible for organisation of care plan in home situation First contact person for patient and caregivers Linking pin to the multidisciplinary team members Information and education to district nursing teams Advice on regulations concerning care etc.