Navigating the Advanced MS Case Load from Fighting Fire to Quality Care

By Maria Grace Hazlett, MS Nurse Specialist, Central London Community Healthcare NHS Trust & Jody Barber, Lead MS Physiotherapist, Central London Community Healthcare NHS Trust


Project write up

Advanced multiple sclerosis home visit

Advanced multiple sclerosis describes the scale of burden that MS is having on an individual rather than the type of MS they have. This could be multiple/concurrent symptoms of MS that are ongoing, dependence on others for some or all their care and support needs, significant impairment of function, people with advanced MS make up a significant proportion of AMS caseload. There is limited data locally in West Herts however it is proposed that 30-40% of the MS population in our area have advanced multiple sclerosis.

Review of local Hess data shows hospital admissions are increasing in this client group. As mentioned in the poster above, the GEMMS audit highlighted that in West Herts people with advanced multiple sclerosis are often not in contact with the services.

We have developed a caseload of 294 people with advanced MS identified as having advanced multiple sclerosis. These are the patient’s known to our service and are aware that this is by no means a complete picture. With the development of new pathways and the transformation plans we hope to further address this inequality.

We hope to pursue improvements including a named professional to coordinate care and take a leading role in the ongoing management this is likely to be a multiple sclerosis nurse specialist or AHP.

We are also looking further into personalised care plans and intend to develop a template to bring to our multidisciplinary team. Our service is currently undergoing a commissioning review, we have developed 3 levels of pathways, bronze, silver, gold.

What happens at point of referral: multiple sclerosis specialist nurse has designed the professional and patient self-referral forms to enhance the quality of information on referral and reduce time spent on triage.

Appropriate patient identified at triage Initial assessment previously completed by member of Herts Neuro Service MS Team which is usually the multiple sclerosis nurse specialist.

Ethnicity, smoking, PHQ9, GAD7, EQ5D5L, MS self-reported tool already completed before attending the visit these documents are sent out via post by admin with appointment letter.

Where : Patient’s home

Who Attends: Two disciplines relevant to needs identified at triage MS Nurse / physio / OT

Length of Clinic: 9O mins

Frequency: once a month pro rata. We have established through doing the clinics that it would be optimal to increase the clinics to fortnightly. Due to reduced staffing levels this is currently not possible

Function of clinic: offer a proactive and responsive MDT approach, that will respond effectively and timely, coordinated intervention in the confines of this clinic.

What a happens at clinic; multiple sclerosis nurse specialist will have actions referrals to outside agencies prior to the home visit. The MS team has identified which disciplines are required and what are the current needs. Completes MS self-reported Assessment and hands in Completed Key performance indicator.

Patient supported with identifying top 3 impairments from the MS self-reported questionnaire. From this the therapeutic need is assessed and agreed with patient and therapist. Appropriate assessment and advice completed.

Visual analogue scale completed

The following outcomes are:

Discharged from therapy intervention with ongoing referrals to relevant external agencies

Referred to other specialist pathways within service

A maximum of one to three follows up appointment can be offered to consolidate the educational and advice offered in assessment and then discharged from therapy intervention

Patients continue under MS nurse review as appropriate

It is intended that ongoing audit on a yearly basis will be completed by the MS team. Increased partnership with other teams, such as palliative care, respiratory services, social services, MS therapy centres.

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