Multiple Sclerosis Pathway - Provider Information: Coordination of Care
Through a lifetime of symptom management and worsening disability, an MS patient can expect to see multiple care providers, try multiple prescriptions and supports, and go through multiple transitions in care. In this environment, best practice guidelines recommend that people with MS be offered a single point of care to help with coordination and access.
The neurologist, family doctor, and MS nurse are encouraged to work closely on navigating patients to multidisciplinary resources. It is very important for all care providers to collect and share patient information.
Patients must also have access to MS education and information, and to their care team. Conversation with patients should be open, proactive, and ongoing.
NICE Guidelines for management of patients with MS recommend all people with MS have a comprehensive review of all aspects of their care at least once a year, involving professionals with expertise in MS as well as those providing day to day care.
The comprehensive review should encompass:
- disease progress/relapses;
- symptoms and management;
- general health (weight, healthy behaviours, exercise, access to routine health screening, contraception, care of chronic conditions);
- social activity and participation (including family and social circumstances, driving and access to transport, employment, access to daily activities and leisure);
- review of care (including personal care needs, social care needs, access to adaptations, and equipment at home); and
- medication review in line with regional policies.
Caregivers should be included as part of the patient’s care plan. Patients and caregivers should be made aware of resources to support them in their community.