Multiple Sclerosis is an autoimmune disorder that affects all areas of the central nervous system. Although there is no cure for MS, there are effective treatments available. Although immunomodulatory drugs affect progression of the disease, proper care involves more than just medication. Effective symptomatic treatment can have a major impact on quality of life. Each patient is different and treatment plans must be individualized to patient needs.
Comprehensive care ensures that all patient needs are attended to through a multi-disciplinary team-based approach. It employs teams of medical providers who are specially trained to care for MS patients.
Core Team members To Include:
- Multiple Sclerosis Neurologist (team leader)
- Multiple Sclerosis Nurse Practitioner
- General Medicine Nurse Practitioner
- MS-certified Case Manager
- Social Worker
- Medical Assistant
- Team Medical Clerk
There are many resources in the community which can be brought to bear in support of the comprehensive care of patients and families. Coordination among providers and community partners results in a patient-centered environment that covers all facets of MS patient needs including medical, physical, educational, spiritual, alternative, and social. That’s why Core Teams need the support of a Coordination Team that ensures integration of all aspects of care within and outside the facility.
Future Coordination Team members:
- Patient Navigator
- Community Partner Coordinator
- Education Coordinator
- Hospital/Transition of Care Coordinator
Comprehensive care clinics are dedicated to the highest quality of patient care while still bridging the gaps to patient and caregiver education, social services and care coordination. Ideally, patient, family and caregiver involvement and shared decision-making enhance the total care of the patient.