Pre-Activity Assessment / Evaluation Form

Pre-Activity AssessmentPlease 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 FormPlease 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, 20155:00pm Registration6:00pm Briefing/Dinner6:15pm CE Presentation

Bristal Assisted LivingThe Bistro Room40 Merrik AveEast Meadow, NY 11554

Faculty

Patricia K. Coyle, MD, FAAN, FANAProfessor and Vice Chair Clinical AffairsDirector, MS Comprehensive Care CenterProfessor of NeurologySUNY at Stony BrookStony Brook, NY

Amber Casteel, RN, CCMChattanooga Chapter CMSA PresidentChattanooga, TN

Agenda

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

CE Information

Purpose StatementThe purpose of this activity is to enhance competence of nurses and case managers concerning the treatment of MS.

Target AudienceThis educational activity is directed toward case managers practicing in the management of Multiple Sclerosis.

SponsorThis activity is sponsored by Medical Learning Institute

Inc.

Commercial Support AcknowledgmentThis activity is supported by educational grants from Acorda Therapeutics, Inc and Genzyme, a Sanofi company.

Credit Designation

Registered Nurse DesignationMedical Learning Institute IncProvider approved by the California Board of Registered Nursing, Provider Number 15106, for 1.0 contact hour.

Case Manager DesignationThis 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: 140001527To claim these CEs, log into your CE Center account at www.ccmcertification.org.

Learning Objectives

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

Disclosure

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.

Faculty Disclosure

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.

Disclaimer

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.

Instructions for Credit

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 Inc203 Main Street, Suite 249Flemington, NJ 08822609.333.1694 (fax)

For questions regarding the accreditation of this activity, please contact Medical Learning Institute Inc at 609.333.1693 or cgusack@mlicme.org.

To claim CEs for Case Managers, log into your CE Center account at www.ccmcertification.org.

Review Recent Data on the Burden of MS to Patients,

Families, Employers, and the Health Care System

Patricia Coyle, MD, FAAN, FANAProfessor and Vice Chair Clinical AffairsDirector, MS Comprehensive Care CenterProfessor of NeurologySUNY at Stony BrookStony Brook, NY

MS Burden

• Background

• Impact features

• Cost

Background

• 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.

Determine Accurate Prevalence of MS

• 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

Background

• 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 disabled1] National MS Society. Fact sheet: MS. Accessed Dec 19, 2013.

Impact Features1

• 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.

Impact Features

• 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) issues1] Wundes A, et al. J Med Econ. 2010;13(4):626-632.

Key MS Issues

• 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

MS Symptoms

• Depression• Fatigue• Cognitive issues• Spasticity• Ambulation difficulties• Neurogenic bladder• Bowel dysfunction• Pain• Speech, swallowing, vision issues• Sexual dysfunction

MS Costs

• 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.

MS Costs

• 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.

Update on New and Emerging Therapies for the Treatment and

Symptom Management of MS

Current DMTs

• First-line parenterals

• Second/third-line parenterals

• First-line oral agents

First-Line Parenterals

• 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)

IM indicates intramuscular; SC, subcutaneous.

First-Line Parenterals

Pros

• Tried and true, known entities

• Long-term data

• Established safety profile

First-Line Parenterals

Cons

• Injectables

• Generics are looming, along with more competition

1]Jeffrey S. Medscape News. January 29, 2014.

Second/Third-Line Parenterals

• 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)

Second-Line ParenteralsNatalizumab

Pros

• High efficacy

• Assured compliance

• Well tolerated

Cons

• Increased risk for progressive multifocal leukoencephalopathy (PML)

Second-Line ParenteralsNatalizumab

Second-Line ParenteralsMitoxantrone

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.

Second-Line ParenteralsMitoxantrone

Third-Line Parenteral Alemtuzumab

• 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

Third-Line Parenteral Alemtuzumab

•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.

Third-Line Parenteral Alemtuzumab

Pros

• Assured compliance

• Therapy over two years involves only 8 days

• Long lasting effects/induction therapy

• High efficacy

Third-Line Parenteral Alemtuzumab

Cons

• Risks for autoimmune disorders (thyroid 36%, ITP 2%, kidney <1%)

• Monthly monitoring for 4 years after last treatment

• Prolonged antiviral prophylaxis

First-Line Oral AgentsFingolimod

• 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

First-Line Oral AgentsTeriflunomide

• 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

First-Line Oral AgentsDimethyl fumarate

• 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

First-Line Orals

Pros

• Oral convenience

• Very good efficacy

• Well tolerated (for the most part)

First-Line Orals

Cons

• Limited experience

• Limited safety or efficacy data

• Each oral has its own unique adverse events and tolerability issues

Unmet Needs

• Pathogenesis not fully established

• No proven therapies for progressive MS (slow worsening)

• No CNS restorative therapies

• No cure

Unmet Needs

• 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

Future Therapies

• Anti-B-cell strategies

• Other agents

Anti-B-Cell Strategies

• Anti – CD20s

– Rituximab (chimeric)

– Ocrelizumab (humanized)

– Ofatumumab (human)

Other Agents

• 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

Other Agents

• 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.

MS Symptomatic Therapies

• 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.

MS Symptomatic Therapies

• Onabotulinumtoxin A

– For overactive bladder

– Injection into bladder muscles

– May need to catheterize

MS Symptomatic Therapies

• 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.

Summary

• 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

Case Scenarios: Patient-centered Treatment and Management Approaches from a

Neurologist’s Perspective

Case 1

• 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

Case 1

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?

Case 1

Case 1: Issues

• Non-adherence

• Poor knowledge base

• Poor side effect management

• Poor communication

Case 2

• 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

Case 2

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.

Case 2

What are the issues in this case?

Case 2: Issues

• Poor knowledge

• Poor communication

• Unrecognized relapses

• Monitoring/surveillance MRI

• Suboptimal responder/treatment failure

Case 3

• 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

Case 3

• 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

Case 3

What are the issues in this case?

Case 3: Issues

• Moderate / severe disability

• Multiple symptoms poorly managed, if at all– Ambulation / foot drop

– Depression

– Fatigue

– Neurogenic bladder

– Spasticity

– Pain

Case 3: Issues

• Poor sleep hygiene

• Social isolation

• Fall risk

• Unsafe environment

Effective Patient Support Strategies

The Case Manager’s Perspective

Amber Casteel, RN, CCMChattanooga Chapter CMSA PresidentChattanooga, TN

Urgent Need for Effective Coordination of Care

• 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.

Role of the Case Manager

• 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

Where to Find a Case Manager

• 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 settingsPCP indicates primary care physician

8 Major Domains:Standards Used by all Case Managers

• All case managers use the following domains to assess an individual’s needs and/or barriers to their prescribed plan of care:– 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

Case Managers Need More MS Knowledge

• 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

Educate Patients to Recognize Progressive Illness!

Knowledge to Make Informed Decisions & Achieve Positive Outcomes

• Symptoms

– Mild or severe

• Long duration or short

• Various combination

• Muscle

• Bowel & bladder

• Eye

• Numbness, tingling or pain

• Other brain and nerve symptoms

• Sexual symptoms

• Speech and swallowing

• Fatigue

Physiologic Function

• 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

Educating Patients and their Support Network

• 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

Checklist for the Individual

• 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

Optimize the Patient-Physician Visit Preparing the Patient

• Case managers need resources/tools to coach MS patients on the optimal visit with the neurologist

Action Required

• 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

Optimize the Patient-Physician Visit

Preparing the Neurologist

• Case managers need resources/tools to help prepare the neurologist for the optimal visit with the patient

Action Required

• 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

Key Items to be Addressed by the MS Treatment Team

• 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

Discuss Treatment Options to Control Symptoms

• Spasticity

• Weakness

• Trouble with walking

• Optic Symptoms

• Fatigue – physical and psychological factors– Avoid excessive activity and heat

• Depression – treat with meds as appropriate

• Pain

• Bladder malfunction

• Sexual dysfunction

Working with the Individual

Based upon the individual assessment and needs, the case manager will target interventions to reduce and/or remove barriers to care:• Physical therapy, speech

therapy, occupational therapy, and support groups

• Assistive devices, such as wheelchairs, bed lifts, shower chairs, walkers, and wall bars

• A planned exercise program early in the course of the disorder

• A healthy lifestyle, with good nutrition, enough rest and relaxation

• Avoid fatigue, stress, temperature extremes, and illness

• Suggest changes in what an individual eats or drinks if there are swallowing issues

• Make changes around the home to prevent falls/home evaluations

Treatment Options

• Slow Progression: Beta Interferons

– Side effects include injection site reaction

– Liver damage is a possibility

– Requires CBC, liver enzyme, and thyroid monitoring

Common Side Effects of DMTs Used to Reduce the Number of MS

Attacks • 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.

• 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.

Apply Principles of CMAG and Motivational Interviewing

• 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.

Working to Improve Adherence

• 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

Does the Patient Have a Case Manager?

• The neurologist and other treatment team members need to ask MS patients whether they have a case manager

Action Required

• 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

Report Back to the PCP and Medical Home

• 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)

Action Required

• 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

Things IndividualsCan Do for Themselves!

• 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

The Case Manager: A Valuable Asset to Patients,

Caregivers & the Treatment Team

• 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

Support the Caregiver

• 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

Action Required

• 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

Adapt Successful Models

• 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

Resources Available

• 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

Summary

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

Summary

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

Summary

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

PANEL DIALOGUE - HEALTHCARE TEAM:

BEST PRACTICES FOR INTEGRATED MANAGEMENT OF THE MS PATIENT TO

IMPROVE OVERALL OUTCOMES