Program Overview

The MS Care intervention is a patient-centered collaborative care model for people living with multiple sclerosis, who are also coping with chronic pain and/or depression. Multiple sclerosis (MS), a chronic neurodegenerative disease, is the most common cause of acquired neurologic disability in young adults. (1) MS onset is typically between ages 20 and 50, and thus most individuals with MS live many years managing a diverse array of co-occurring physical, cognitive, and psychological conditions. (1)

 

HOW DOES MS CARE DIFFER FROM USUAL CARE?

MS Care is an intervention that is offered above and beyond usual care, enhancing key elements of care that are not typically emphasized under typical care models.

Illustration of ways in which MS Care enhances and differs from usual care. Click to be directed to an enlarged diagram.

Illustration of ways in which MS Care enhances and differs from usual care. Click to be directed to an enlarged diagram.

The additive element of MS Care is highlighted in the diagram to the right. Key elements include:

  • Flexibility: The intervention is offered in the clinic or over the phone, thereby increasing access to patients who may not otherwise be able to receive care. 
  • Tailoring: Treatment is provided by highly trained clinical social workers in the role of care manager who can tailor the treatment to meet the individual needs of each patient.
  • Dedicated care management: Collaborative care has the benefit of the care manager as part of the MS healthcare team, whose focus is monitoring, tracking, treating, and coordinating depression and pain management.
  • Systematic monitoring: Care is systemized such that outcomes are routinely tracked and monitored electronically, and treatments adjusted accordingly.
  • Proactive: Collaborative care utilizes evidence-based principles and strategies to engage patients in care, build motivation, and reach out to those who may not be adhering to the program.
  • Rapid adjustment: Treatment is quickly adjusted and intensified as needed through the consultation and coordination with domain experts.

In the end, MS Care hopes to achieve better outcomes by engaging the patient in the system, rather than the components, of the intervention.

HOW DOES MS CARE WORK?

MS Care services are provided in addition to the current care a patient receives from his or her providers. Patients partner with a MS Care Manager (MS-CM) who guides the intervention by using evidence-based approaches to support MS patients who experience pain and/or depression. The treatment involves weekly sessions with the MS-CM to discuss symptom management, assess the effectiveness of medications, and learn how to  practice self-management skills. The MS-CM meets weekly with MS pain and depression management experts and UW Medicine MS Center providers to tailor the treatment to the patient’s specific needs. The MS-CM communicates regularly with providers, and helps to connect the patient with the MS Center and additional resources to ensure comprehensive care support. A central philosophy of MS Care is that the patient is ultimately in charge of his or her care and decides where he or she wants to start in making meaningful changes.

 

PROGRAM HIGHLIGHTS

Patient-centered: Engages patients based on their strengths, values and goals.

Flexible: Offers patients a choice of treatment over the phone or in the clinic.

Tailored: 6-12 treatment sessions, delivered by a Master’s level Care Manager, that include the following:

  • Measurement-based care facilitated by screening at every session for pain severity, pain interference and depressive symptoms, to track and build awareness of ongoing symptoms
  • Medication monitoring, with dedicated assessment at every visit of current medication use and the associated  effectiveness, side-effects, and adherence
  • Non-pharmacologic intervention (e.g., a psychology intervention) for pain and/or mood
    • A flexible intervention designed to meet the specific needs of the patient, with components rooted in empirically-supported treatments, such as cognitive-behavioral therapy.
      • Core components provided to all participants: psycho-education regarding pain and depression; self-monitoring of their symptoms; exploration of their values and what is important to them; relaxation training; goal setting and behavioral activation
    • In between session activities (homework) to extend session progress
    • A relapse prevention plan focused on maintaining skills & gains made in the program

Monitored: A team of depression and pain experts serve as consultants to the Care Manager.

Maintained: A post-treatment booster session to ensure maintenance of gains.

Five Principles of Effective Collaborative Care

adapted from https://aims.uw.edu/collaborative-care/principles-collaborative-care

 

MS Care Roles

 
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patient

In MS Care the patient is an integral member of the team, participating in shared decision making around his or her care, tracking outcomes and reporting updates to the MS Care Manager. 

ms care manager

The MS Care Manager engages the patient by providing education, assessment and planning, monitoring medication adherence and effectiveness, and delivering non-pharmacologic treatment for pain and/or depression either in the clinic or over the phone.  The MS Care Manager works closely with patient and team members to monitor and coordinate care. As treatment nears conclusion, a key component is the MS Care Manager partnering with the patient to create a plan to help maintain the newly-learned skills. 

patients existing ms medical team

The MS Medical Team (neurology and rehabilitation medicine providers in the MS center) refers patients to collaborative care and remains involved through sharing information across team and acting on recommended modifications in the patient’s treatment plan. The MS Medical Team continues to have their typical appointments with patients and are welcome to participate in weekly case consultation. 

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caseload consultants

This team consists of experts in the domains of MS, pain, and depression management (psychologists, psychiatrist and pain expert). The team consults with the MS Care Manager with an emphasis on new and non-improving cases. The Caseload Consultants guide care by providing expert opinion and recommending specific treatment approaches to maximize the effectiveness of the care. Together, they provide comprehensive, patient-centered coordinated care geared towards reducing a patient's pain and/or depression.

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consultants

The MS Care Manager coordinates referrals to additional providers (e.g., community partners, physical therapists) as needed to support treatment outcomes of improving depression and/or pain management.

Patient Experience

As part of MS Care you will participate in a “collaborative care” treatment model that utilizes a team of medical and psychological experts in the treatment of two of the most prevalent issues that often go hand in hand with MS: chronic pain and/or depression. A key feature of MS Care is the collaboration between you, a care manager (MS-CM), and your care providers. While your care is coordinated by a MS-CM, you are at the center of this collaboration, and in the driver’s seat of managing your care. A care manager will support you along your journey, with the long term goal of giving you the tools you need to navigate your symptom management and care support on your own. 

HOW DOES MS CARE WORK?

  • MS Care services are provided in addition to the support you receive at the the MS Center and from your providers. You will continue to see them for regularly scheduled MS follow-up visits, emergencies or questions not connected to our work together.
  • You will partner with a MS-CM who guides the intervention by using evidence-based approaches to support people living with MS who experience pain and/or depression.
  • This treatment involves weekly sessions with a MS-CM to discuss how symptom management is going, assess the effectiveness of medications, and learn and practice self-management skills.
  • The MS-CM meets weekly with MS pain and depression management experts and MS Center providers to tailor treatment to your specific needs, and to ensure all members of your care team work together to provide holistic and coordinated care.
  • The MS-CM will help connect you to other members of the MS Center Team and resources as needed for comprehensive support.
  • While the MS-CM will share information and strategies with you that have been helpful to others living with MS, ultimately you are in charge of your care. You will be the one who decides where you want to start in making meaningful changes.
  • You will work with the MS-CM for 6-12 weeks, depending on your needs. After completing treatment, the MS-CM will check in with you to see how you are integrating new skills to manage pain and/or depression.
  • Treatment takes place at either the MS Center or over the phone.

you can expect the care manager to:

  • Provide evidence-based information about options for managing pain and/or depression.
  • Be supportive. The MS-CM is here to (a) support you as you make changes in how you are managing your health and (b) help find strategies that will work for you and your lifestyle.
  • Understand that problems you face may feel overwhelming. The MS-CM can help you find ways to break down solutions into smaller, manageable pieces, and help you with the steps along the way.
  • Help you figure out whether medications may be helpful for your pain/mood management, and help you manage taking the ones you and your medical team select.
  • Understand that you are in charge of your health. The MS-CM is here to help, but you are the one in the driver’s seat on your health journey. 

in order to achieve the best possible results, we expect ms care patients to:

  • Commit to attending your weekly appointments and provide clear, timely communication if appointments need to be rescheduled.
  • Be willing to apply what we discuss in treatment to your daily life. You’ll see the most benefits from self-management skills with regular practice.
  • Speak up if you have questions or concerns. We want to make this program work for you!
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