What’s Here for You

  • The importance of a multidisciplinary team approach
  • Understanding the evolving treatment landscape
  • The value of a shared decision-making process
  • Examples of tools you can use to facilitate decision making

The importance of care coordination in MS

People with MS can greatly benefit from collaborative case management that includes hands-on care coordination. By being actively involved with their patients, care managers can improve communication and resource utilization to improve clinical outcomes. 27

Ensuring optimal coordination and transitions of care can benefit even the most challenging of MS cases. And as the point person, the more you know about the overall healthcare team and plan the more you’ll be able to help your patients.

The multidisciplinary approach

Studies have shown that a multidisciplinary team can most effectively and efficiently provide treatment for people with MS. Members on this team may include a neurologist, nurse, primary care clinician, mental health professional, social worker, patient advocate, care partner, and others. Each specialist brings expertise to help meet the various needs of the person with MS. 28

In addition, the patient is an important part of the multidisciplinary team. In this model, the patient is empowered as an active participant in planning and implementing their care plan through a shared decision-making process. 28,29

Careful coordination among healthcare professionals can improve many aspects of care. This approach can also advance the level of coordination of services and continuity of care to reduce redundancy or fragmentation of resources. 27,28

Download My Healthcare Team PDF

You can find a list of common MS medications on the National Multiple Sclerosis Society’s website

Shared decision making

Patients should be made to feel like their opinions are being heard when treatment decisions are being made.29

When considering a new or different therapy, it is important that the patient, their support partners, their clinicians, and their insurer understand the risks and benefits of treatment and agree on the appropriate course of action. 27

Get suggestions on helping patients be more engaged with their treatment

Helpful tools to encourage shared decision making

Tools you can use to promote decision sharing include 12:

  • Goal setting to inspire your patients to set realistic and achievable goals. Download My MS Goal-Setting Guide PDF 
  • Patient decision aids, which increase patient engagement 
  • Health coaching, which improves health status
  • Discussion guides, to be used by patients along with their healthcare providers, can empower patients. Download My MS Discussion Guide PDF 
  • Self-management education and support, which may improve adherence to treatment

Setting goals

Setting clear and realistic goals is a great way to help your patients feel more positive about life with MS. When patients define their treatment goals and achieve them, they are more likely to be satisfied with their care.

Download My MS Goal-Setting Guide PDF

Identifying gaps in coordination of care

Patients with chronic conditions are more likely to experience poorly coordinated care, which can lead to adverse drug interactions, unnecessary or duplicative tests or procedures, conflicting information from multiple providers, and increased healthcare costs. 30

Minding the gap improves communication

Gaps in care coordination can have several origins. Communication often breaks down when patients are transitioned from one site of care to another. At other times, gaps can stem from poor communication between providers. Or there may be a misunderstanding between an office practice manager and a pharmacist or specialty pharmacy provider. Whatever the scenario, your early intervention can help identify and fill these gaps so your patients can receive optimal care.

Guidance for improving communication between patients and their healthcare team

If you believe there are gaps in care coordination it is important to connect the relevant multidisciplinary team members. With improved communication, you can help ensure your patients are receiving optimal care. Care managers are key to closing the gap.

The National Transitions of Care Coalition (NTOCC), an independent third-party organization, is dedicated to ensuring effective transitions of care by helping patients play a more active role. The NTOCC provides resources and strategies to healthcare managers so that they can better understand and improve care transitions. 31

Learn more at the National Transitions of Care website

What You Can Do

  • Identify the multidisciplinary team for your patients
  • Work with patients to promote shared decision making 
  • Identify gaps in care coordination when they occur and alert the appropriate healthcare provider
  • Consider hosting a healthcare team conference over the phone to align on treatment and care goals