Interdisciplinary Clinics Within A MS Program: A Novel Approach To Comprehensive Care

Background: The Multiple Sclerosis (MS) program at the IRDPQ Institut Universitaire de Réadaptation, a rehabilitation center in Quebec City, provides medical, rehabilitative and psychosocial services to 1400 patients, with 50 new patients being admitted each year.  This high volume of patients presenting with evolving multidimensional needs, along with the desire to provide comprehensive, coordinated, patient-centered care were the catalysts that pushed the MS program to develop a unique concept of care: Interdisciplinary Clinics (ICs).

Objectives: The purpose of the ICs is to efficiently identify and prioritize the patients’ pharmacological, physical and functional needs and to offer a concerted plan of action that optimizes available resources and patient quality of life.

Methods: The ICs are held weekly and are offered to patients identified as having more complex rehabilitation needs.  Consisting of an hour-long assessment performed by a core team composed of a neurologist, a nurse practitioner, an occupational therapist and a physical therapist, they include a medical review, a thorough questionnaire covering the patients’ activities of daily living, a brief physical assessment, a neurological exam and, if needed, a wheelchair assessment.  Many of the patients’ needs can be met immediately, within the timeframe of the hour-long assessment.  For items that require greater attention or other areas of expertise, referrals are made to partners within the rehabilitation center or community organizations for further assessment and follow-up.

Results: This comprehensive, interdisciplinary approach has proven to be beneficial on many levels.  Therapists and doctors report great satisfaction in working as a team and appreciate the opportunity to determine common goals and to better understand the patients’ overall rehabilitation needs. Furthermore, this approach eliminates unnecessary repetition of information-gathering allowing for a more efficient use of therapists' and patients’ time.  To date, patients have reported a high satisfaction rate in the services they have received at the clinic.

Conclusions: The weekly ICs provide coordinated services that address the many and varying aspects of MS care in an efficient and timely manner thus contributing to the end goal of maximizing quality of life for people with MS.