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Multiple Sclerosis Centers of Excellence


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Multiple Sclerosis Social Workers Professional Page

Meet our MSCOE Social Workers
Maggie Kazmierski, MSW, LCSW-C, CCM is a MSCoE-East Senior Social Worker and the Spinal Cord Injury Clinic Coordinator for the Baltimore VAMC in Baltimore, MD.
Alicia Sloan, MPH, MSW, LICSW is a core Research and Projects Coordinator with MSCoE-West at VA Puget Sound Health Care System in Seattle, WA.
Jan Spencer, MSW, LCSW is the social worker for MSCoE-West as well as the Epilepsy Center of Excellence-Northwest in Portland, OR.

VA MS Social Workers…
♦ Are knowledgeable about MS and how it affects the psychosocial aspects of daily life of a Veteran with MS.
♦ Use evidence-based social work practice methods especially focused in MS.
♦ Stay up-to-date with the changing MS disease process and how it affects the Veteran in daily life.
♦ Address the unique needs of the Veteran MS population.
♦ Serve the comprehensive social work needs of Veterans with MS and their families throughout the disease course.
♦ Work in a multidisciplinary MS Care Team in planning, implementation, and evaluation of MS treatment programs.
♦ Conduct psychosocial assessment and high risk screenings of the Veteran with MS.
♦ Formulate a social work component of the overall MS treatment plan.
♦ Serve many roles: Case Manager, Advocate, Counselor, Facilitator, Educator, Negotiator.

Need intensive case management help for a Veteran with MS? The National MS Society MS Navigator Program can help!
VA providers can refer a Veteran with MS to the National MS Society's MS Navigator Program.
Call 1-800-344-4867 for details.

Monthly Calls for Professional Networking with other MS Mental Health Providers - Sponsored by the National MS Society: Contact to get on the listserv for calls.

Professional Resources for MS
VA Multiple Sclerosis Centers of Excellence (MSCOE) 
MSCOE Network Facilities Directory
MSCOE Health Care Professionals Page 
MS Directive: VA System of Care VHA Directive 1101.06 
MSCOE Research
National MS Society - Professional Resource Center  For extra help for case management, the National MS Society offers the MS Navigator Program.
VA Social Work
VA Social Work Reference Center - Database approved for CEUs - reference sheets, quick lessons, full text pdfs of journal articles.
Online Social Work Journals on VHA National Destop Library

Training Opportunities
REACH VA-MS Caregiver Program Coach with new REACH VA-MS Caregiver workbook.
- General Training  Telephone Based Training
The Consortium of Multiple Sclerosis Centers (CMSC) - Become a MS Certified Specialist

MS Annual Conferences
Consortium of MS Centers (CMSC) Annual Meetings
Paralyzed Veterans of America (PVA) Summit

MS Veteran Resources 
Distribute the MS Veteran Booklet and latest MS Veteran Newsletters
MSCOE Veteran Webpage

Caregivers of Veterans with MS Resources
MSCOE Caregiver Webpage

VA Resources
Advance Directives
Benefits on MSCOE website
Geriatrics and Extended Care
Home and Community Based Services
Mental Health
PTSD: National Center for PTSD   PTSD Program Locator
Respite VA - in-home respite
Social Work Reference Center
Substance Use   Substance Use Disorder (SUD) Program Locator
Suicide assessment/prevention 
Facts about Veteran Suicide July 2016
- MIRECC for Suicide Prevention
Telehealth Services MSCoE and Telehealth Services (TS) collaborate to develop telehealth programs within the VISNs for CVT, CCHT, and SFT that will address the specific needs of Veterans with MS. To ensure quality and safety standards are met, MSCoEs and TS need to develop policies that are in line with national telehealth operations and goals.
Service-Connection for Multiple Sclerosis disability benefits
Telemental Health. TeleMental Health Clinical Services are used to treat virtually every DSM (Diagnostic and Statistical Manual) diagnosis, including affective disorders, anxiety disorders/PTSD, psychotic disorders, and substance use disorders. 
VA Website for Veterans
VA Library

National Resource Directory
National Resource Directory is a partnership among the Departments of Defense, Labor and Veterans Affairs. It is a resource website that connects wounded warriors, Service Members, Veterans, their families, and caregivers to programs and services that support them.

Social Work Organizations/Resources
National Association of Social Workers (NASW)
NASW Code of Ethics
NASW Standards for the Practice of Clinical Social Work
NASW Standards and Guidelines

MS Social Workers play many roles on the MS Care Team
(adapted from handout by Jan Spencer, MSW, LCSW)


- Provide psychosocial assessment
- Promote mental, vocational, and social rehabilitation.
- Facilitate the Veteran’s return to the community at the highest level of functioning possible.
- Assess the needs and barriers of the Veteran and primary Caregiver (spouse, partner, family member, friend) and formulate a plan.
- Assess home environment.
- Assess Activities of Daily Living (ADLs) and Inactivity of Daily Living (IADLs)
- Discuss H/HHA and put in the consult to get them on the EWL.
- Assess MS Caregiver needs: Refer to VA in-home respite, general VA Caregiver resources, and VA Home and Community Based Services
- Identify VA & Community resources and follow up for outcome, like MS Organizations:
  National MS Society
  United Spinal Association
- Link Veteran to a Veterans Service Organizations (VSO)
  Paralyzed Veterans of America 
  Disabled American Veterans 
  Veterans of Foreign Wars
- Link necessary VA departments/services together to best serve the Veteran and Caregiver.
- Partner with other professionals in Mental Health, Primary Care and other service lines to provide comprehensive management of resources, support systems and services to Veterans/Family.
- Assist with alternative living arrangements when necessary
- Assist with travel benefits.



  • Advocate for health care services inside and outside of VHA: If unable to work or beginning to have difficulty, we can provide information on SSDI and how to apply/qualifications, etc.
  • Advise on Veteran’s benefits and VA compensation programs
  • Intercede and speak in defense of the Veteran’s well-being.
  • Advocate for Veteran’s needs and desires in their care following a Patient Centered Model
  • Navigate with Veteran through the VA health care system and private sector.
  • Encourage Veterans to call if having problems with issue, cannot get a resolution, or have a question and have no idea who to ask.
  • Navigate through common barriers and assist with removing barriers to other needed services. 
  • Help expedite health services. 
  • Check for service-connected for MS using Veteran’s date of service and when symptoms began.
  • Link to VSO if other SC conditions or worsening conditions.
  • Provide education and assist with Advanced Care Directives (ACD) or review existing ACD. Does ACD still reflect their goals of care?
  • Communicate with other primary service areas and VAs or needs in that community. Locate their social worker there.



  • Facilitate Veterans/Caregivers together for peer support: MS support groups, telephone support groups, caregiver support groups.
  • Topics identified by our Veterans.
  • Offer meetings by V-tel, Clinical Video Telehealth, VANTS conference call.
  • Develop relationships with community organizations that support Veterans with MS and their family/caregivers.
  • Respond to calls for financial assistance, transportation, etc.


  • Inform not only the Veteran/Family, but also colleagues on resources, support programs and systems for Veterans with MS and their caregivers.
  • Provide education to Veterans with MS, families, and interdisciplinary team members on the psychosocial impact of illness and disease progression.
  • Provide MS specific materials: MS Veteran Booklet, MS Veteran Newsletters.
  • Advise Veterans regarding VA benefits and compensation programs.
  • Provide education on planning for care with the use of Advanced Directives.


  • Provide mediation between the Veteran and the Health Care System.
  • Assist in resolving Veteran and caregiver conflicts.
  • Provide supportive counseling as appropriate.
  • Assist in resolving systemic conflicts that impact the care of the Veteran.

    Created May 2017