An Interdisciplinary Approach to Home Care Management of the Multiple Sclerosis Patient

Nancy Popp, RN,
Liaison - Fairview Home Care and Hospice,Minneapolis, Minnesota,USA Karen Hunter, RN, C
Program Specialist, Clinical Supervisor - Fairview Home Care and Hospice,Minneapolis, Minnesota,USA

A group of staff from Fairview Home Care and Hospice, Minneapolis, Minnesota, wanted to provide quality home care to people with MS. The treating team comprised a program specialist, mental health nurse, social worker, physical therapist, occupational therapist and speech/language therapist. They identified five key issues: communication, safety, education, compliance and autonomy. Communication was improved by case conferences involving the people with MS, family and caregiver. Safety issues were addressed by assessing the physical environment, especially transfers and making home care dependent on recommendations being followed. Team members actively sought information and resources relating to MS and this was shared with people with MS, their families and home care staff. An information pack was produced, including a pamphlet about living creatively with a chronic illness. Understanding of cognitive difficulties was openly promoted in a caring manner to improve compliance. The goal of the team was to keep people with MS as independent as possible for as long as possible.

In 1994, a group of professional staff at Fairview Home Care and Hospice (FHCH) met to discuss the concerns and challenges they often experienced caring for their patients with Multiple Sclerosis(MS). Plans of care often times seemed fragmented rather than cohesive. Patients and families expressed frustrations with home care staff and many times seemed to have unrealistic expectations of what services home care could provide. The ultimate goal of this group was to provide quality home care to their patients.
The professional staff consisted of an MS program specialist (PS), mental health nurse, social worker (SW), physical therapist (PT), occupational therapist (OT), speech/language pathologist (SLP), chaplain, and hospital liaison. They discussed their need for more knowledge about MS as a disease process and the effects of chronic illness on patients and families. Concerns about the patient’s safety in his own home and the safety of his caregivers was addressed. Often patients were not adhering to the plan of care set in place by the case manager and other professional staff. Some patients had frequent admissions to home care because not all of their needs were addressed on the initial admission.
The recommendation from this group was that an interdisciplinary team be formed to assist home care staff in managing the delivery of services to the MS patient population. Each of the professionals at this initial meeting chose to be part of the newly formed interdisciplinary MS Team. The PS would act as team leader. They agreed to meet weekly to continue to develop this new concept and provide assistance to their coworkers in MS patient care management. In addition, the team identified the following key issues to be addressed in upcoming meetings: communication, safety, education, compliance and patient autonomy.
Clear communication between home care providers and professionals is often limited just by the nature of home care. Communication with patients and families can easily be misinterpreted causing problems or obstacles in carrying out the plan of care. The team made a commitment to improve communications between all disciplines involved in a patient’s care and with patients and their families.
A segment of each team meeting was set aside for case conferences and updating team members on the progress being made in the care plan development. Patient-family-caregiver conferences were initiated to explain the plan of care, getting all the key players together to hear the same information at the same time. Clarification of issues could also be accomplished at this time. Patients, families and caregivers are encouraged to participate in the development of a plan of care.
Updating the physician is a key element in the success of the care plan. Without physician support the plan developed by the team could easily fail.
A major goal of the team is the safety of the patient in his own environment. The physical environment is assessed for safety as well as the patient’s ability to be safe in his environment. Recommendations are made to change unsafe situations and these recommendations become part of the care plan.
Not only is the safety of the patient assessed but the safety of the home care staff and family members providing direct cares for the patient is also addressed. Patient transfers are always an area of great concern. Transfers are evaluated and recommendations are made for the safety of all involved. On occasion, the patient or family member may refuse to follow the recommendations made. If this happens, the patient and family are informed that the home care staff will not be able to participate in unsafe transfers.
Each of the disciplines shared their areas of expertise and identified their patient care responsibilities. This allowed each team member an increased awareness of how to utilize each other for a total patient evaluation.
Team members identified a need for more information and knowledge about the disease, its effects on patients and their families, payor sources and resources available to patients. The PS obtained reference materials and journal articles and shared them with the team. Guest speakers (neurologists, a social worker in private practice, and a neuro-psychologist) were invited to speak to the group. Members attended conferences and continuing education seminars. The team made a visit to the Minnesota Chapter of the National Multiple Sclerosis Society to learn about its services and programs. Team members also attend the monthly education hour offered by the Fairview Multiple Sclerosis Center.
A commitment was made to educate the home care staff caring for MS patients. Inservices were developed for all disciplines to increase their knowledge about MS and how to utilize the MS Team. These inservices explained about the disease, its impact on the patient and family. The importance of following the plan of care was emphasized.
Patients and families were frequently asking for more information. A packet of information was created which included a pamphlet about living creatively with a chronic illness, a brochure about the services offered by the Fairview MS Achievement Center, a registration form for the National MS Society and a listing of free educational materials offered by the Society. A list of advocacy resources, information about accessing community resources and a MS Resource Directory were developed. Patients and families are encouraged to explore avenues of information and support within the community.
The team reached out into the community to educate care givers, insurance case managers and other professionals. Mini seminars were presented which included a case study with ample time for questions and discussion.
Nonadherence to the plan of care many times can be linked to the cognitive changes that may occur in the disease process. Often patients are aware of subtle changes that have occurred and are too embarrassed or too frightened to bring them to anyone’s attention. The MS Team has chosen to deal with cognitive changes openly and in a caring manner. With this approach, patients, families and home care staff have a greater understanding of what is happening and what can be done about it. Better understanding promotes improved compliance with treatment plans and care plans.
Patient Autonomy
Each patient situation is approached on an individual basis and the whole picture taken into consideration. The goal of the team is to keep the MS patient as independent as possible for as long a possible, retaining individuality and self-worth at a time when his body is posing a threat to his independence. Recommendations may consist of one simple change or piece of adaptive equipment to multiple changes, several new pieces of equipment or even moving to more accessible housing. The plan of care is continuously adapted to accommodate the change in a patient’s capabilities.
Cost effectiveness is not to be ignored. At first glance, a patient-family conference, including several members of the MS Team and case manager may not appear to cost effective since insurance cannot be billed for the conference. The team finds that presenting the plan of care to the patient and family at the same time ensures that everyone is hearing the same information. Since the patient and family have been involved in developing the plan of care, usually only minor changes or adjustments are needed.
Mini Case Study
The following mini case study will give the reader a better understanding of the team’s interdisciplinary approach.
DK , a 54-year old woman, was recently diagnosed with MS. She was admitted to the acute rehabilitation unit during an exacerbation. Following steroid treatment and intensive rehabilitation therapies she was discharged to home with nursing and PT services from FHCH. She declined the services of a home health aide to assist her with personal cares. On initial assessment by the RN case manager, DK was found to need nursing to monitor the steroid taper, the effects of the steroid taper and effects of other medications. In discussion with the nurse DK related that she was interested in moving into a more accessible apartment. The case manager obtained orders for a SW to assist DK with exploring accessible housing and other community resources. While the SW made her visit, she observed that DK was grieving multiple losses due to her disease and, with the patient’s approval, made a referral to the chaplain. At the initial PT evaluation, DK’s gait was unsteady and the apartment was cluttered with furniture and various items laying around. The PT assessed DK for the appropriate assistive device to make her safe when walking and a walker was ordered. DK was not able to get into the tub for a shower without assistance. The PT taught DK about the importance of having safe walkways free of clutter and how to have her family help her rearrange her furniture to provide more room for her to get around.
After the evaluations were complete, a patient-family conference was scheduled. DK asked her son, Randy, and daughter, Susan, to be present at the conference. The case manager, PT, SW and chaplain attended the conference. The SW facilitated the meeting. Safety concerns were discussed. The patient agreed to have a home health aide visit three times a week to assist her with bathing and using the shower. Randy and Susan agreed to help their mother move the furniture to provide more accessible walkways. Following the conference the PT would teach the son and daughter the proper use of the walker when assisting their mother. The PT recommended an OT evaluation when DK moved into a new apartment. The SW shared information about various housing opportunities. DK and her family had many questions about MS and additional services available to her in the community. The chaplain explained to Randy and Susan about the grieving process and how to support their mother at this time. Information about MS was shared with DK and her family and a MS Information Packet was given to them for further review. The team continued to provide services to DK until shortly after she moved into her new apartment.
Providing quality home care services with a safe plan of care for MS patients is the continuing goal of the MS Team. The team continues to do this by making a commitment to work together through an interdisciplinary approach. The team works with physicians, payor sources, patients and their families to develop a safe plan of care. Team members share a passion to provide quality care to MS patients that will allow them to remain independent in their own environment.

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