MS Care Manager
Effective delivery of the MS Care intervention requires unique knowledge of MS, the target problems (depression and pain), and the collaborative care approach. Care Managers in the MS Care Study were two master’s level social workers, one with experience in depression and pain management in MS, and the other with experience delivering collaborative care and depression management. Essential characteristics for this role include: flexibility; mental health experience; an ability to establish rapport with a wide range of people, to work as a team and collaborate with others.
Training was provided for both care managers with an emphasis on leveraging their existing individual experience to cross-train each other. Co-investigators with relevant expertise provided formal initial training in the collaborative care approach, treatment of pain and depression in multiple sclerosis, and study procedures. Didactic training was provided via lecture, experiential training, and online resources. Given the breadth of treatment and the unique element of utilizing an individually-tailored treatment model, the study also included ongoing training via individual and group supervision on a weekly basis, at a minimum.
care manager activities
- Provide education and a patient-centered engagement session, focusing on assessment and treatment planning
- Elicit patients’ goals and preferences for depression and/or pain treatment, and initiate treatment plan consulting with both patient and MS provider
- Provide brief psychotherapy (by phone or in-person, based on patient preference) with treatment tailored to targeted problems and patient needs
- Monitor patient closely using structured assessments of pain and depression for changes in severity of symptoms, medication side effects & response to treatment;
- Educate patients about medications and medication side effects, as needed to encourage treatment adherence
- Participate in weekly caseload supervision with consultant team, and communicate recommendations for changes in medication and treatment plan to patient and MS medical team
- Coordinate and facilitate communication between patient, MS providers, and consulting team
- Document each session, including outcome measures and any coordination with providers in Electronic Health Record (EHR)
- Facilitate referrals, as needed
- Complete relapse prevention plan with patients who are in remission
- Consistently reach out to patients to maintain contact, monitor outcomes and deliver treatments