The challenge of integrating care in dual diagnosis; Anti-NMDA-receptor encephalitis; presentation and outcome in 3 cases referred for Complex Specialist Rehabilitation

Introduction : The successful implementation of an integrated care pathway for any given condition is a challenge. Even more challenging is the successful implementation of integrated care for individuals who have multiple co-morbidities which cause activity limitation and participation restriction. This is further compounded when there is dual mental health and physical disabilities that require integrated working across multiple disciplines, specialties, institutions and organisations. Even more complex is the situation where there is a rare diagnosis that results in dual pathology  and the management of these is the purpose of this study. Anti-NMDA-Receptor encephalitis is a relatively new diagnostic entity with patients typically presenting with significant psychiatric symptoms followed by progressive neurological deterioration. More than 50% are associated with tumours, especially ovarian teratoma. Methods : Retrospective analysis of the interdisciplinary case notes of 3 cases of females with anti-NMDAR encephalitis with complex mental and physical impairments, activity limitation and participation restrictions who were referred for complex specialist interdisciplinary rehabilitation to a National Rehabilitation Hospital. An analysis of demographics, presenting features, management and outcome was performed. Results : Implementation of a bespoke multimorbidity care pathway that crossed diagnostic, disciplinary, specialty and organisational boundaries resulted in improved activities of daily living and participation for these patients who will continue their rehabilitation in the community with health and social care support. Discussion : Patients with anti-NMDA receptor encephalitis can present to different specialties in different care settings (psychiatry, general practice, acute general settings) which can result in variability in management, delays in treatment and unsatisfactory outcomes for patients. Although typically associated with paraneoplastic syndromes, this disease also occurs in absence of neoplasm which can present a more challenging treatment path. A high index of suspicion is required in these cases and mobilisation of a wide number of care professionals to develop a person centred coordinated care plan. There are currently no clear guidelines on the management of these patients and a variety of treatment regimens may need to be tested before clinical improvement is seen. Response to treatment can be delayed so there is a need for integrated care across a number of specialties, disciplines and settings to deliver improved outcomes for these patients. Without key enablers such as an integrated healthcare record, being in place, this can often be a challenge. However, even In the absence of such enablers, excellent communication and co-ordination is possible. In each of the cases, Rehabilitation services acted as the coordinator of services to ensure implementation of the treatment plan and to ensure successful transitions of care and ultimately transition to the community with appropriate flow up and supports. Physicians need to have a basic understanding of the clinical characteristics, differential diagnosis, treatment regimens and Rehabilitation requirements of these patients and integrated care pathways should be in place to ensure patient centred co-ordination of care to ensure optimum outcomes for patients.