Sustaining Care
The goal of the nurse in sustaining MS care is focused on maintaining well-being, coordinating referrals, identifying community resources, and advocating for comprehensive care. 3 Nurses continually reformulate the patient’s primary and long-term goals of care. They exercise their role as advocates, helping fulfill patient needs while maintaining good stewardship of resources. Nurses sustain the therapeutic relationship over time, providing caring throughout the MS disease trajectory.
As the disease progresses, nurses are vigilant to both prevention of complications and management. In this regard, the MS Assessment Tool is a useful portal to document dynamic changes in disability and therapy and track AEs. Infection, pain due to immobility, wounds, difficulty with respiration and swallowing, and neurogenic bowel and bladder are initially assessed and managed while preserving the patient’s physical, emotional, and spiritual values. Last, nurses cultivate relationships with other providers for personalized referrals, ensuring continuity and efficiency of care. 4
The nurse and William discussed his greatest difficulties, which were primarily social. Without a job or income, William relied on savings to pay his mortgage, car loan, utilities, and other bills. William admitted that he had very little money to buy food as his savings dwindled. The nurse connected William with both VA social workers and a veterans service organization (VSO) and brokered a relationship for William with a community organization, the local chapter of the National Multiple Sclerosis Society (NMSS).
Benefits and Assistance
The NMSS was able to offer some limited financial assistance. William enrolled in a support group for newly diagnosed patients sponsored by NMSS and joined a class for people with MS and balance difficulties. The VSO helped William with his application for service connection for his disability. Multiple sclerosis is considered service connected if neurologic symptoms leading to a diagnosis are established during the military career or within 7 years of service discharge. 6 William’s first symptom occurred 5 years after his army discharge. The social worker helped William apply for Social Security Disability Insurance (SSDI). The nurse also wrote letters, and he was subsequently approved for both SSDI and VA service connection for his MS. As a result, William accessed vocational rehabilitation services through the Veterans Benefits Agency.
Consults to prosthetics and rehabilitation services are essential for optimizing patient safety and energy. The opportunities for William in the VA health care system exceeded many private sector plans in that all medically necessary durable medical equipment is available without charge. William was able to focus on managing his MS without worries about food, shelter, or health care.
The neurology outpatient clinic brings the nurse, neurologist, physiatrist, neuropsychologist, social worker, dietitian, urology, occupational and physical therapists, wound care nurse, and prosthetics representative together in one place. Patients can access the care of each discipline during a single clinic visit. Quality of care, cost savings in travel, and patient satisfaction are clear rewards. When William encountered difficulty driving to the VA
for clinic appointments, he was referred to the Driving Program at selected sites and evaluated for assistive technology in his vehicle or an adaptive vehicle.