An ankle-foot orthosis could address William’s foot drop. An assistive device, such as a cane or walker, could also help minimize falls associated with ataxia. It is important to screen patients for psychological impacts of loss of function and psychological barriers to the use of assistive devices; referral to a rehabilitation psychologist may be warranted. Last, William’s walking speed was slightly impaired. When speed of walking is a concern, patients might benefit from a trial of dalfampridine once walking safety has been optimized.
MS Care Models
Because MS is a dynamic disease, producing multifocal neurologic deficits and disability, a wide range of health care specialists are required to assist in MS care throughout the life of the patient. The neurologist is typically the principal caregiver, but referrals to rehabilitation specialists, psychologists, ophthalmologists, urologists, speech pathologists, wound specialists, and social workers are common. Multiple sclerosis advocacy groups within the U.S. frequently promote multidisciplinary care. Yet few attempts have been made to define multidisciplinary MS care models or to test their effectiveness. Like other chronic conditions, coordination and continuity of care for patients with MS are often suboptimal.
About 30,000 patients with MS use the VA health care system. Treatment takes place largely in outpatient clinics. Patients with MS require more visits per person than do all but a handful of other patient populations. Multiple sclerosis therapy includes complex and expensive pharmacologic agents as well as multidisciplinary medical and rehabilitation services and assistive technology. In 2003, after surveys showed wide and unexplained variations across the VA in the care of patients with MS, 2 MSCoE coordinating centers were established to improve access to MS specialty care, develop national standards of care, and implement those standards through a network of regional MS programs.
With input from the MSCoE and a network of more than 70 VA MS programs, the VA Central Office released a handbook for MS care in December 2009. The VA handbook Multiple Sclerosis System of Care Procedures is the first MS health care policy directive that has been created, outlining a comprehensive plan of care for patients with MS. 9 The handbook describes the diagnostic and therapeutic health care services that are required by patients with MS, including primary care, MS specialty care, rehabilitation, palliative care, respite care, home care, long-term care, mental health care, social work services, telehealth services, and access to disease-modifying and symptomatic pharmacologic therapies.
According to the MS handbook, every patient with MS should receive an annual evaluation in which the care plan is reviewed with a provider who is knowledgeable about MS. The provider then completes the required MS Assessment Tool within the CPRS. The annual visit and MS Assessment Tool help to identify patients with MS, track medication AEs, and populate the VA national MS surveillance registry. Ideally, this evaluation takes place in
a face-to-face visit with a MS subspecialist. However, this requirement also could be satisfied by a visit with another provider knowledgeable about MS or through a video or telephone telehealth interview.