The Effects Of a Long-Term Multidisciplinary Disease Managment Program: A Case Report

Background: There is a paucity of evidence for the use of long-term multidisciplinary care lasting longer than six months for persons with multiple sclerosis (MS). This case report describes the results of a person’s year-long episode of care in the Chronic Disease Management Program (CDMP), a multidisciplinary, medically-based rehabilitation service and health management program for persons with MS. The CDMP provides services based on each person’s needs. Services include physical, behavioral, occupational, speech, and cognitive therapies, and health education.

Objectives: The first objective of this case report is to describe a year-long episode of care in the CDMP of a person with moderate MS-related disability. This includes a summary description of the services provided, and measurements that describe the person’s status after the intervention. The second objective is to describe the feasibility of the CDMP in improving function and participation for persons with MS.

Methods: Baseline testing was conducted by the CDMP team at intake. The CDMP team applied a standard set of measures. Also, each discipline conducted an examination. The designation of services was determined based on goals identified by the person with MS and the CDMP team. Once the person’s progress stabilized, a transition to the maintenance phase was initiated. If issues arose during the maintenance phase or at a quarterly assessment that indicated need, the person reentered the skilled phase. This cycle was repeated over the year-long period.

Results: The person completed the one-year intervention period despite three unexpected events: two separate orthopedic foot injuries, and a crisis of hope and optimism. These problems were identified early through the CDMP’s ongoing assessments. This facilitated implementation of interventions which enabled the person to continue participation in the CDMP. The person completed an entire year of the CDMP.

Outcomes: From baseline to the one-year measurement point, the person improved in 7/9 completed items of the MS Quality of Life Inventory, in the 25’ Timed Walk, 9-hole Peg and 3-second Paced Serial Addition tests, and in the 6-minute walk and Four-Square Step tests. In addition, there was a notable reduction in the frequency of reported falls.

Conclusions: In this case study, the year-long CDMP resulted in substantial improvements from baseline for this person with moderate MS-related disability. Despite a number of potentially problematic events, the person was able to adhere to this long-term program. The CDMP shows promise as an efficient, effective and feasible multidisciplinary intervention program. Further study is required to determine the feasibility and effectiveness of this long-term multidisciplinary program for persons with MS of different severities.