Transcript Event Handout - CMSA Long Island

Pre-Activity Assessment
Please take a moment to complete the pre-activity
assessment prior to the start of the activity.
The pre-activity assessment is inside the front of the
workbook.
Evaluation Form
Please take a moment at the conclusion of the activity to
complete the evaluation form in the back of the workbook.
On-site staff will collect all forms at the conclusion of the
activity.
Wednesday, April 8, 2015
5:00pm
6:00pm
6:15pm
Registration
Briefing/Dinner
CE Presentation
Bristal Assisted Living
The Bistro Room
40 Merrik Ave
East Meadow, NY 11554
Patricia K. Coyle, MD, FAAN, FANA
Professor and Vice Chair Clinical Affairs
Director, MS Comprehensive Care Center
Professor of Neurology
SUNY at Stony Brook
Stony Brook, NY
Amber Casteel, RN, CCM
Chattanooga Chapter CMSA President
Chattanooga, TN
I
Review updated data on the burden of MS, including
patients, families, employers, and the health care system
II
Discussion of new and emerging therapies for the
treatment and symptom management of MS
III
Case Scenarios: Patient-centered treatment and
management approaches from a neurologist’s perspective
IV Review of effective management strategies for improving
overall outcomes from the case manager’s perspective
based on evolving interventions and total cost of care
V
Summary and Q&A
Purpose Statement
The purpose of this activity is to enhance competence of nurses and case
managers concerning the treatment of MS.
Target Audience
This educational activity is directed toward case managers practicing in the
management of Multiple Sclerosis.
Sponsor
This activity is sponsored by Medical Learning Institute Inc.
Commercial Support Acknowledgment
This activity is supported by educational grants from Acorda Therapeutics, Inc and
Genzyme, a Sanofi company.
Registered Nurse Designation
Medical Learning Institute Inc
Provider approved by the California Board of Registered Nursing,
Provider Number 15106, for 1.0 contact hour.
Case Manager Designation
This program has been pre-approved by The Commission for Case
Manager Certification to provide continuing education credit to CCM®
board certified case managers. The course is approved for 1.0 CE
contact hour.
Activity code: C00011511
Approval Number: 140001527
To claim these CEs, log into your CE Center account at
www.ccmcertification.org.
Upon completion of this activity, the participant will be
able to:
• Define how the decline in QoL in MS patients impacts
productivity
• Determine the issues that complicate and interrupt
early diagnosis, treatment, and medication adherence
• Review current understanding of the treatment and
symptom management of MS through case scenarios
• Formulate effective, personalized management
strategies for improving outcomes and QoL for patients
with MS
Before the activity, all faculty and anyone who is in a position to have control over
the content of this activity and their spouse/life partner will disclose the existence of
any financial interest and/or relationship(s) they might have with any commercial
interest producing healthcare goods/services to be discussed during their
presentation(s): honoraria, expenses, grants, consulting roles, speakers bureau
membership, stock ownership, or other special relationships. Presenters will inform
participants of any off-label discussions. All identified conflicts of interest are
thoroughly vetted by Medical Learning Institute Inc for fair balance, scientific
objectivity of studies mentioned in the materials or used as the basis for content,
and appropriateness of patient care recommendations.
The associates of Medical Learning Institute Inc, the accredited provider for this
activity do not have any financial relationships or relationships to products or devices
with any commercial interest related to the content of this CE activity for any
amount during the past 12 months.
Name of Meeting
Planner/Manager
Company
Reported Financial Relationship
William Wong, MD
Medical Learning Institute Inc
Has nothing to disclose.
Patricia Coyle, MD, FAAN, FANA is a Consultant for Accordant,
Acorda, Bayer, Biogen, Genentech/Roche, Genzyme/Sanofi,
Mylan, Novartis, Serono, and Teva. She also received Research
Grants for Actelion, Genzyme/Sanofi, Novartis, and Opex. She
does not intend to discuss any non-FDA-approved
investigational use of any products/devices.
Amber Casteel, RN, CCM has nothing to disclose. She does not
intend to discuss any non-FDA-approved or investigational use
of any products/devices.
The information provided at this CE activity is for
continuing education purposes only and is not meant
to substitute for the independent medical judgment
of a healthcare provider relative to diagnostic and
treatment options of a specific patient’s medical
condition.
Recommendations for the use of particular
therapeutic agents are based on the best available
scientific evidence and current clinical guidelines. No
bias towards or promotion for any agent discussed in
this program should be inferred.
There is no fee for this activity.
To receive credit for this CE activity, please take a few minutes to complete the
pre-activity assessment and evaluation form and return it to the on-site
coordinator. Your confirmation of reported participation will be e-mailed to you
within 4 weeks. If you choose to complete this evaluation form off-site, return it
by mail or fax to:
Medical Learning Institute Inc
203 Main Street, Suite 249
Flemington, NJ 08822
609.333.1694 (fax)
For questions regarding the accreditation of this activity, please contact Medical
Learning Institute Inc at 609.333.1693 or [email protected].
To claim CEs for Case Managers, log into your CE Center account at
www.ccmcertification.org.
Patricia Coyle, MD, FAAN, FANA
Professor and Vice Chair Clinical Affairs
Director, MS Comprehensive Care Center
Professor of Neurology
SUNY at Stony Brook
Stony Brook, NY
• Background
• Impact features
• Cost
• Multiple sclerosis (MS) is the most common acquired
neurologic disease in young adults1
• At least 400,000 affected in the US2 and 2.3 million
worldwide3
• MS is on the rise (among women)
• MS affects people who are relatively young (majority are
diagnosed between the ages of 20-50 years)3
1] NINDS. MS: hope through research. Accessed Dec 18, 2013. 2] National MS Society. Take action.
Accessed Dec 18, 2013. 3] National MS Society. Fact sheet: MS. Accessed Dec 18, 2013.
• There is a distinct need for more accurate data
on the prevalence of MS in the United States
– This information is vital to new drug development,
clinical studies, and the funding of resources,
programs, and services for patients with MS
• Female predominant1
• Two major clinical patterns1
– Relapsing
– Progressive
• Untreated MS results in disability in the
majority of patients over time (cognitive,
motor, vocational)
• All progressive MS patients become disabled
1] National MS Society. Fact sheet: MS. Accessed Dec 19, 2013.
• Disease directly disrupts patient’s daily life
• Impact on family and friends (caregiver burden)
• Impact on health system/society
1] Wundes A, et al. J Med Econ. 2010;13(4):626-632.
• Economic burden
– Direct, indirect, and intangible costs
– Intangible costs accounted for 17.5%–47.8% of total costs1
– Intangible costs were correlated with worsening disability1
– Productivity loss
– Cost of therapies and care
• Symptoms and quality-of-life (QoL) issues
1] Wundes A, et al. J Med Econ. 2010;13(4):626-632.
• Early diagnosis is important
– Paves the way for early counseling and treatment
• No single diagnostic test is currently available
• Early therapy is likely ideal
– Therapy is aimed at reducing future injury/issues
– The importance of early treatment must be explained
carefully to patients in order to maximize treatment
adherence
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Depression
Fatigue
Cognitive issues
Spasticity
Ambulation difficulties
Neurogenic bladder
Bowel dysfunction
Pain
Speech, swallowing, vision issues
Sexual dysfunction
• Costs increase with disease severity
• Mean annual cost to treat MS in US (2009)
was $23,434
– DMTs account for 69% of total costs
• MS was third highest cost per patient for brain
disorders in 2010 Switzerland ($32,412)
1] Naci H, et al. Pharmacoeconomics. 2010;28(5):363-369. 2] Owens GM, et al. J Manag Care
Pharm. 2013;19:S42-S53. 3] Maercker A, et al. Swiss Med Wkly. 2013;143:w13751.
• Medicare (2006) costs for MS were $23,630 for
progressive MS; $5,887 for relapsing MS
• Newly diagnosed MS show significantly higher
rates of hospitalization/radiology
services/ER/OPD visits vs. controls
1] Gilden DM, et al. Value Health. 2011;14(1):61-69. 2] Asche CV, et al. J Manag Care Pharm. 2010;16(9):703-712.
• First-line parenterals
• Second/third-line parenterals
• First-line oral agents
• Three interferon β (IFNβ) 1a (IM 30 mcg weekly;
SC 44 mcg 3x weekly; SC PEG 125 mcg Q 2 weeks)
• Two IFNβ1b (SC 250 mcg every other day)
• Glatiramer acetate (20 mg SC daily or 40mg SC
3x weekly)
Pros
• Tried and true, known entities
• Long-term data
• Established safety profile
Cons
• Injectables
• Generics are looming, along with more competition
1]Jeffrey S. Medscape News. January 29, 2014.
• Natalizumab (300 mg IV monthly)
• Mitoxantrone (12 mg/m2 IV every 3 months;
lifetime max 140 mg/m2)
• Alemtuzumab (12 mg IV daily x 5 days year
one; daily x 3 days year two)
Pros
• High efficacy
• Assured compliance
• Well tolerated
Cons
• Increased risk for progressive multifocal
leukoencephalopathy (PML)
Pros
• High efficacy
• Assured compliance
• Prolonged efficacy (induction agent)
Cons
• No longer used for MS (in US)
• Associated with cardiomyopathy and
treatment-related leukemia
– FDA recommends that patients who ever received
mitoxantrone receive a yearly quantitative LVEF
evaluation to detect late-occurring cardiac toxicity.
AML indicates acute myeloid leukemia; LVEF, left ventricular ejection fraction.
• Humanized IgG1 kappa anti – CD52
monoclonal antibody
• Cytolytic antibody depletes T cells (CD4 more
than CD8), and to a lesser extent B cells; NK
cells; monocytes and dendritic cells
•Treatment cycle involves five days of 12 mg/day
IV in first year; three days of 12 mg/day IV in
year two (given with IV methylprednisolone)
•This is induction strategy (effects last ≥ 5 yrs)1
1] Coles AJ, et al. Neurology. 2012;78:1069-1078.
Pros
• Assured compliance
• Therapy over two years involves only 8 days
• Long lasting effects/induction therapy
• High efficacy
Cons
• Risks for autoimmune disorders (thyroid 36%,
ITP 2%, kidney <1%)
• Monthly monitoring for 4 years after last
treatment
• Prolonged antiviral prophylaxis
• 0.5 mg PO daily (0.25 mg dose is being tested)
• Sphingosine 1-phosphate receptor modulator
(binds to receptor 1, and 3, 4, 5)
• Phosphorylated product blocks ability of naïve
and central memory T-cells to exit lymph nodes;
CCR7- effector memory T-cells are not affected
• Also enters CNS to potentially have direct effects
• Cardiac, pulmonary, ocular concerns
• 14 mg PO daily (7 mg also available)
• Cytostatic rapidly dividing (activated) B and T
lymphocytes
• No affect on resting or slowly dividing
lymphocytes
• Active ingredient of leflunomide (treatment
for RA and psoriatic arthritis)
• Pregnancy, hair thinning concerns
• 240 mg PO twice a day
• Fumaric acid (citric acid energy cycle) ester
• Affects Nrf2 oxidative stress, direct effects on
lymphocytes and dendritic cells
• One of two key components of psoriasis
product in Germany
• Gastrointestinal, flushing concerns
Pros
• Oral convenience
• Very good efficacy
• Well tolerated (for the most part)
Cons
• Limited experience
• Limited safety or efficacy data
• Each oral has its own unique adverse events
and tolerability issues
• Pathogenesis not fully established
• No proven therapies for progressive
MS (slow worsening)
• No CNS restorative therapies
• No cure
• Every agent shows variable therapeutic
response
• No biomarkers to select optimal agent, or to
determine therapeutic response quickly
(personalized medicine)
• Current clinical trial outcomes have
limitations
• Anti-B-cell strategies
• Other agents
• Anti – CD20s
– Rituximab (chimeric)
– Ocrelizumab (humanized)
– Ofatumumab (human)
• Daclizumab
– Humanized anti-CD25 monoclonal antibody
– Targets activated T- and B-cells
– Expands CD56 bright NK cells (may predict
treatment response)
– Given IV or SC
– Completed Phase III trial
• Second generation S1P receptor modulators
(BAF312; ONO-46414; ponesimod)
• Vaccine therapies (Tovaxin, BHT-3009,
Neurovax)
– Transdermal (myelin peptide) skin patch1
1] Walczak A, et al. JAMA Neurol . 2013;Sept 1;70(9):1105-1109.
• Dalfampridine
– Potassium channel blocker
– Extended release product
– 10 mg PO twice daily
– Improves ability to walk (in 35 - 43% of patients with
all 4 types of MS disease course)1
– Can improve nerve conduction
– Contraindicated with seizures or renal impairment
1] Ampyra (dalfampridine) prescribing information. 2013.
• Onabotulinumtoxin A
– For overactive bladder
– Injection into bladder muscles
– May need to catheterize
• Dextromethorphan (20mg)/Quinidine (10mg)
– Pseudobulbar affect1
– Acts on sigma-1, NMDA receptors
• Tetrahydrocannabinol / Cannabinoids
– Pain/spasticity
1] Nuedexta (dextromethorphan hydrobromide and quinidine sulfate) [prescribing information]. 2010.
• MS is in the era of DMTs
• Choices are expanding, making therapeutic
decisions more complex
• We should expect key advances to move us
into the next stage – personalized medicine
• A.S. is a 25-year-old female recently diagnosed with
relapsing MS
• She had the disease for three years, with two attacks
and complete recovery
• She was started on dimethyl fumarate 3 months ago
• She is also on vitamin D3, 4000 units daily and
vitamin B12, 2000 mcg daily, because her vitamin D25
hydroxy level was 19, and her B12 level was 310
In speaking to the patient, she has been having
problems with nausea and vomiting since starting
the dimethyl fumarate, and is actually only taking it
once a day because she tolerates it much better.
She is also only taking her vitamin supplements
sporadically. When asked if she has discussed this
with her doctor, she states that she has not. On her
most recent visit, she didn’t bring any of this up
because she didn’t want to interfere with her
doctor’s examination.
What are the issues in this case?
• Non-adherence
• Poor knowledge base
• Poor side effect management
• Poor communication
• B.L. is a 36-year-old man with a 5-year history of
relapsing MS
• He has been on daily injection of SC Glatiramer
Acetate
• He indicates that he missed a week of work last
month when he had bronchitis
• He also developed paresthesias of his right leg, and
his right knee gave out several times
• He is still limping slightly/favoring that leg
He never informed his doctor that he usually
develops neurologic issues whenever he has
significant infections.
When asked about his last brain MRI, he
conveyed his last MRI was 5 years ago at the
time of diagnosis.
What are the issues in this case?
• Poor knowledge
• Poor communication
• Unrecognized relapses
• Monitoring/surveillance MRI
• Suboptimal responder/treatment failure
• R.M. is a 54-year-old woman with an 18-year
history of MS
• She uses a cane or walker to get around
– Tends to trip over her toes
– Falls frequently
• She appears apathetic and sad
– Overwhelming fatigue in the afternoon
• Patient R.M. rarely leaves the house because
of bladder accidents
• She complains of painful spasms at night with
poor sleep; during the day, her right leg
suddenly stiffens painfully for <1 minute; this
limits her mobility
What are the issues in this case?
• Moderate / severe disability
• Multiple symptoms poorly managed, if at all
– Ambulation / foot drop
– Depression
– Fatigue
– Neurogenic bladder
– Spasticity
– Pain
• Poor sleep hygiene
• Social isolation
• Fall risk
• Unsafe environment
Effective Patient
Support Strategies
The Case Manager’s Perspective
Amber Casteel, RN, CCM
Chattanooga Chapter CMSA President
Chattanooga, TN
• Effective care coordination initiatives could result
in a staggering $240 billion savings in annual US
healthcare costs, according to the Institute of
Medicine (IOM)1
• Use of a case manager is a key strategy toward
improving patient-centered care coordination
– Leads to improved outcomes and reduced costs
1] IOM. 2010. Washington, CD: The National Academic Press.
• Facilitate cohesive, patient-centered planning
• Communicate: Assist in building strong
communication (patient, PCP, neurologist,
nutritionist, physical therapist, nurse, speech
therapist, social worker)
• Advocate for options
• Educate
• Address Barriers
• Implement Interventions
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Clinic models / outpatient settings
Managed care organizations/health plans
Accountable care organizations, joint ventures
Acute care settings
Specialty-based settings
PCP-based settings
Independent case management
Rehab-focused settings
Vendors
Home health care
Other settings
PCP indicates primary care physician
• All case managers use the following domains to
assess an individual’s needs and/or barriers to
their prescribed plan of care:
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Psycho-social function
Cultural factors
Health literacy and linguistics
Financial factors
Spiritual and religious functioning
Physical and environmental safety
Family and community support, or other source of
support
• It is important for case managers to become
well-versed/knowledgeable about the
management of MS
– This is particularly relevant with respect to
treatment-related adverse events and comorbid
conditions
– Consider adapting approaches from other
effective educational models, ie, diabetes,
congestive heart failure, other chronic illnesses
• Symptoms
– Mild or severe
• Numbness, tingling or
pain
• Long duration or short
• Other brain and nerve
symptoms
• Various combination
• Sexual symptoms
• Muscle
• Speech and swallowing
• Bowel & bladder
• Fatigue
• Eye
• Each individual has specific needs:
– Primary Progressive MS
• Disease progression from onset, with occasional
plateaus and/or temporary minor improvements
• May have one or more superimposed relapses
– Secondary Progressive MS
• Initial relapsing remitting course followed by
progressive; with or without occasional relapse,
minimal remission or plateaus
• Education is vital to improving outcomes
• Symptoms vary
• There is no cure, but treatment may help
lessen MS attacks, manage symptoms, and
reduce disease progression
• Be prepared for your visit
• Write down any symptoms
• Write down important personal info (stress in your life, any
recent major changes)
• List of medications
• Take a family or friend with you
• Make a list of questions for the physician
• Guidelines as to how to communicate with the physician
(succinct, frame questions appropriately) and when to contact
the specialist in-between visits
• Case managers need resources/tools to coach
MS patients on the optimal visit with the
neurologist
• Case manager’s role in preparing the patient for the
face-to-face specialist visit
– Develop a 1-page “Top-10” checklist for the patient, to
include:
• Any new medical or surgical issues; symptom occurrence
• All current prescription drugs
– Patient can take close-up cell-phone photo of med. bottles
• Questions the patient should ask/how to frame the questions
• How to communicate with the physician clearly and succinctly
• When to contact the physician—not to wait until a crisis arises
– Use a template letter; customize variables
– Place reminder call/text to patients a day or two before
specialist visit to help reduce no-shows
• Case managers need resources/tools to help
prepare the neurologist for the optimal visit
with the patient
• Case manager’s role in helping to prepare the neurologist for
the MS patient’s visit
– Identifying the patient’s key concerns
– Listing and prioritizing complex, multiple symptoms, comorbid
conditions (tailored to the individual patient)
– Generating relevant checklist, process, and tools
• Cognitive and depression questionnaire, walking test, others
• Create/use a template letter; customize variables
– Integration of recommendations for the individual ‘s plan of care
should be shared with all members of the team
– Placing reminder call to patient a day or two before the
appointment—helps reduce no-shows
• Additional tests that will be necessary
• Progression possibilities
• What treatments are available
• Treatment options
• Side effects of each treatment
• How to manage any other health conditions along with MS
• Restrictions, if any
• Literature, websites, other resources available
• Spasticity
• Weakness
• Trouble with walking
• Optic Symptoms
• Fatigue – physical and psychological factors
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Avoid excessive activity and heat
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Depression – treat with meds as appropriate
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Pain
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Bladder malfunction
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Sexual dysfunction
Based upon the individual assessment and needs, the case
manager will target interventions to reduce and/or remove
barriers to care:
• Physical therapy, speech • A healthy lifestyle, with good
therapy, occupational
nutrition, enough rest and
therapy, and support
relaxation
groups
• Avoid fatigue, stress, temperature
extremes, and illness
• Assistive devices, such as
wheelchairs, bed lifts,
• Suggest changes in what an
shower chairs, walkers,
individual eats or drinks if there are
and wall bars
swallowing issues
• A planned exercise
program early in the
course of the disorder
• Make changes around the home
to prevent falls/home evaluations
• Slow Progression: Beta Interferons
– Side effects include injection site reaction
– Liver damage is a possibility
– Requires CBC, liver enzyme, and thyroid
monitoring
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Glatiramer acetate
– Side effects are uncommon but may include
injection site reactions, flushing, chest pain
or heart palpitations
Fingolimod
– Monitor heart rate for six hours after the
first dose because of potential for
bradycardia. Need to be immune to the
chickenpox virus and vaccinated against the
varicella zoster virus. Other side effects may
include diarrhea, cough and headache
Natalizumab
– Increases the risk of progressive multifocal
leukoencephalopathy (PML). Requires a
blood test that helps detect exposure to the
JC virus that causes PML
DMT indicates disease-modifying therapy; LFT, liver function test.
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Mitoxantrone
‒ Can be harmful to the heart; may cause
cardiomyopathy and treatment-related
leukemia. Maximum lifetime use of 140
mg (m2). No longer used in the US to
treat MS.
Teriflunomide
‒ This oral medication reduces attacks and
lesions in people with MS. LFTs to
monitor serious liver damage. Special
attention for use during pregnancy!
Dimethyl Fumarate
• Most common side effects include
flushing, abdominal pain, diarrhea, and
nausea. May decrease lymphocyte
counts, which can increase risk of
infection.
• Importance of patients and caregivers knowledge of
specific types of MS
• Patients and caregivers willingness and motivation to
“work the plan” (ie, the plan of care)
• Need for support of patients and caregivers to continue
with health behavior change
• Self motivation when symptoms “wax and wane”
CMAG indicates Case Management Adherence Guidelines.
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Identify barriers to following the individual plan of care
Help to remove barriers
Measure knowledge level
Measure willingness to change
Assess coping ability
Provide linkage to community for support
– Patient
– Caregiver
• Identify/address challenges specific to progressive illness
• Assess ability to manage their “normal” lifestyle
• Manage routine preventive health issues with chronic diseases
• The neurologist and other treatment team
members need to ask MS patients whether
they have a case manager
• If the patient does not have a case manager,
the neurologist/treatment team should
suggest that patients check with their health
plan to determine whether a case manager
can be made available to them
• There is a need for the neurologist/treatment
team to communicate with the PCP about the
MS patient’s status and potential red flags (ie,
infection triggers MS relapse)
• Generate best practices for how to
communicate back to the primary care
physician and/or medical home
– Use a template letter and customize it with key
patient information; send it electronically to the
PCP
– Each venue can develop their own customized
tool, ie, form letter or electronic tool, to
link/enhance communication
• Ask questions
• Know when to contact the physician/how to best
communicate with the physician
• Get plenty of rest
• Exercise, as condition allows
• Cool down
• Eat a balanced diet
• Remove stress
• Maintain a normal daily lifestyle as much as possible
• Stay connected
• Enjoy life, pursue hobbies
• Identify and address issues affecting access to care and any
barriers to treatment adherence
• Integrate a holistic approach
• Include strategies to enhance health and wellness
• Address emotional, social, and vocational challenges
• Maximize productivity and independence
• Outline approaches for coping with cognitive function
• Recommend stress support for the patient and the caregiver
• Refer to support group, website, internet, research studies
• Equip the caregiver with the knowledge/resources
so they are as invested as the MS patient
– They should be as knowledgeable as the patient
• Check in on the caregiver’s health and well-being
– Caregivers often suffer from fatigue, depression, and
other health issues
• Educate the caregiver
– Involve the case manager to help with
education/motivational interviewing
– Identify whether the caregiver’s health, work, education,
routine activities are affected
– Develop/offer MS Caregiver workshops at MS Centers,
community neurologist office (similar to diabetes
workshops held by diabetes educators)
• Inform the caregiver about resources available to
them:
– Respite care
– Support groups
– Psychological care
• Incorporate successful aspects of diabetes, other
chronic care models into MS management and
communication, with respect to:
– Patient/caregiver education and/or workshops
– Case manager education
– Case manager communication with patient
– Case manager communication with physician
– Neurologist’s communication with PCP
• Templates can be effective, if variables are
appropriately customized
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Consortium of MS Centers
MS Association of America
MS Foundation
National Multiple Sclerosis Society: NationalMSSociety.org
National Center for Biotechnology Information—MS;
Demyelinating Disease:
www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001747
• Mayo Clinic--Diseases & Conditions—MS:
www.mayoclinic.com/health/multiple-sclerosis/DS00188
• Webmd.com
• eMedicine health.com
• On-line communities:
– Msconnection.org
1. Take steps to determine the accurate prevalence
of MS in the United States
2. Determine the full range of MS-associated costs
(evident and hidden)
3. Endorse/increase awareness of the availability
and value of the case manager among
community neurologists and PCPs
4. Involve the case manager proactively, not just in
crisis mode, but also when the patient is doing
well
5. Case managers need more education/knowledge about MS
management, including AEs and comorbid conditions,
symptom management
6. Case managers need resources/tools to coach MS patients on
the optimal visit with the neurologist
7. Case managers need resources/tools to help prepare the
neurologist for the optimal visit with the patient
8. The neurologist and other treatment team members need to
ask MS patients whether they have a case manager; if not,
patients should be directed to check with their health plan
9. The neurologist/treatment team needs to
communicate with the PCP about the MS patient’s
status/potential red flags; best practices on how to
communicate effectively with the PCP are needed
10. Support the caregiver; provide them with knowledge
and resources; check in on them
11. Incorporate successful aspects of diabetes, other
chronic care models into MS management and
communication