Download Multiple Sclerosis Initiative Care Coordination Responsibilities Chart

Multiple Sclerosis Initiative Care Coordination Responsibilities Chart
Primary Care Physician/
Team
Initial Diagnosis
 Initial assessment of patient
who presents with symptoms
including ruling out other
possible causes to narrow
possibilities
 Initial MRI to identify other
possible causes
Routine Follow-up
 Management of other chronic
conditions such as diabetes
 Screening and initial treatment
of depression
 Psychosocial needs
 Routine screening
 Pharmacological management
when symptoms are stable for
such things as urinary
frequency and pain
 Ongoing education on health &
lifestyle
Neurologist/Specialty Team
Shared
Initial Diagnosis
 Full assessment and definitive
diagnosis of MS, including
access to timely MRI, if
needed and results
interpretation
 Specialized education on MS
(Initial referral may come from a
neurologist who does not
specialize in MS)
Routine Follow-up
 Regular assessment for
disease progression and
therapies
 Disease modifying therapies
including medications
 Spasticity issues
 Nurse consultation with
Primary Care; liaison with
neurologist
Routine Follow-up
 Forms –if form requires multisystem exam (e.g. DL medical)
more appropriate for PC
physician; MS specific exam (e.g.
AISH, CPP) completed by
specialist
o
Often each will contribute
(MS Society or other social
workers frequently assist)
 Referrals to other specialists –
notifying other providers when
there is a potential impact on
care
 Checking injection sites (can be
done by photograph sent in for
advice)
Primary Care Physician/
Team
Episodic Illness/Injury/Relapse
 Management of episodic
illness/injury including plans for
after-hours care
 Triplicate prescriptions for pain
management; keep consistent
with one physician
Neurologist/Specialty Team
Shared
Episodic Illness/Injury/Relapse
 Relapse management
 Some symptom management
including fatigue
 Administration of steroids
Episodic Illness/Injury/Relapse
 Management of depression
 Urinary tract infections
Supportive & Progressive Care
Supportive & Progressive Care
 Coordination of home care
 Monitoring of disease
and other supportive care
progression as needed by
when unable to manage
neurologist, physiatrist
daily living activities
and/or NP and other MS
independently
clinic staff
 Medical care as indicated for
symptoms and/or other
conditions, including home
visits if required (or referral
to others)
Supportive & Progressive Care
 Application for long term care
when required
 Monitoring of disease
progression may be shared
depending on patient location
and other factors