For me, as the neuro navigator in my area, I am that point of contact, and any patient referred into the community neuro rehab service who has MND and hasn't been seen before, or 12 months has passed since last contact will be seen by me at home for a full MDT Assessment. 

This is a full holistic needs assessment. From this, I will then feed into other disciplines and complete onwards referrals as required. 

I will provide a written summary to the patient, GP and MND care centre following my visit with any issues identified and the action plan. 

Patients are then discussed at the neuro palliative meeting that I chair. 

I feel I do not got a lot of information back, however from other disciplines, I do keep an eye on Systm1 in order to follow up things and will ensure things have been followed up / actioned at the neuro palliative meeting. I feel I need to find out the information myself by going through notes rather than receiving letters etc myself.