CG17
Quality of Life Risk Stratification in MS- an Approach to Meeting the Need
Background: Quality of Life (QOL) risk factors in MS vary among individuals coping with the disease. Just as it became necessary at one time to stratify patients into the category of RRMS, SPMS, or PPMS, perhaps the time has come where stratification from a QOL perspective has potential for delivering more focused, comprehensive care. The Total Life Care Clinic (TLC) was established in 2011 at UTSW Medical Center Clinical Center for Multiple Sclerosis in Dallas, Texas. The mission is to comprehensively assess and provide resources for on-going care to prevent life-threatening events (e.g. infection, falls, impaired mobility, psychosocial decompensation) which can lead to hospitalization, increased economic burden, and ultimately decreased QOL for the person with MS. Effective case management promotes individual responsibility, increases patient empowerment, and improves quality of life.
Objectives: During the implementation of this multi-disciplinary program, a risk stratification system was developed in order to more effectively utilize limited healthcare resources to offer maximum assistance to as many patients as possible.
Methods: The TLC team (consisting of NP, Nurses, Social Worker, Physical Therapist, and Dietitian) carefully evaluated the needs of each individual participating in the program and categorized each patient. This stratification was based on four distinct risk categories: 1) those severely compromised by disease progression who need services outside the scope of TLC, 2) those needing ongoing support of the entire TLC team, 3) those who need continued follow up with the provider and social worker, and 4) those who can exit the program after 4 visits as they have learned to manage on their own. The primary determining factors for placement in a particular category included individual progress toward goals and what specific resources are needed.
Results: We plan to present our QOL risk stratification strategy through the use of individual case studies. Our desire is to show that by expanding the MS assessment to stratify quality of life risk factors, a more focused delivery of care can be achieved.
Conclusions: We believe that QOL risk stratification has the potential to impact clinical practice as providers attempt to maximize resources needed for complicated coordination of care.