VHA Handbook 1011
Multiple Sclerosis System of Care Procedures
Background: Multiple sclerosis (MS) is a chronic disabling neurological disease that affects many Veterans. More than 16,000 Veterans with MS receive care in the Department of Veterans Affairs Health Care System (VHS) and over 6,000 of those have service connection for MS. Treatment of MS is largely outpatient but Veterans with MS require more visits per person than all but a handful of other diagnostic groups. Treatment of MS includes complex and expensive pharmacologic agents as well as multidisciplinary medical and rehabilitation services and assistive technology. In 2003, because of surveys showing wide unexplained variations in the care of Veterans with MS across the VHS, the Department of Veterans Affairs established two Multiple Sclerosis Centers of Excellence (MSCoE) to improve access to MS specialty care, to develop national standards of care and to implement those standards through a network of regional MS programs. VA Central Office (VACO), with input from the MSCoE and a network of over 70 VA MS programs has released a handbook for MS care, “The multiple sclerosis system of care procedures handbook,” VHA Handbook 1011.
Standards of Care: Because of the complex needs of Veterans with MS, care must be comprehensive and multidisciplinary. The handbook describes the diagnostic and therapeutic health care services that are required by Veterans with MS including primary care, MS specialty care, rehabilitation, palliative care, respite care, home care, long-term care, mental health care, social work services, care coordination telehealth services and access to disease modifying and symptomatic pharmacological therapies.
National System of Care: The handbook specifies that the location of care should be dictated by individual needs and should be as convenient for the Veteran as possible. To support this, the handbook outlines a regional hub and spoke network (MS Handbook Figure 2, page 25). Every VISN should support MS Regional Programs (hub sites) staffed with MS subspecialists and other care providers following the guidelines in this handbook (see MS Handbook section 11, page 21-24 and Appendix A). VA facilities without an MS Regional Program are designated as spoke sites and should follow the staffing recommendations for MS Support Programs (see MS Handbook section 12, page 24-25) so Veterans with MS are able to access appropriate services as close to home as possible. The integration of VA care coordination, telehealth and informatics approaches to improve Veteran access to health care services and to provide subspecialist support to spoke sites is encouraged.
Annual evaluations: In order to ensure high quality care, the handbook specifies that every Veteran with MS should undergo an annual evaluation in which the care plan is reviewed by a provider knowledgeable in MS and a simple electronic clinical data surveillance tool (CDS Tool, see MS Handbook Appendix C) is completed. Ideally this would be in a face-to-face office visit for each Veteran with an MS subspecialist but this requirement could be satisfied through primary care with input from a provider familiar with MS or even a telephone interview with the Veteran by a provider knowledgeable about MS.
Funding: Funds are allocated to the facilities to care for Veterans with MS through the Veterans Equitable Resource Allocation (VERA) system. Veterans with MS who have impairments of paraplegia or quadriparesis fall into price group 8. Since 2006, less disabled Veterans with MS have been moved from Price Group 2 to Price Group 4 or 5 depending on whether disease modifying agents are prescribed. This change was determined by VERA to provide local facilities with the resources needed to support the health services required by these Veterans. MSCoE will work with VACO to monitor the funding allocation to facilities for this cohort over time to assure that adequate resources are available for needed care.