Best Practices

The Multiple Sclerosis Centers of Excellence: A Model of Excellence in the VA

Fed Pract. 2020 April;37(1):S6-S10

References

1. US Department of Veterans Affairs, Multiple Sclerosis Centers of Excellence. Multiple Sclerosis System of Care-VHA Directive 1101.06 and Multiple Sclerosis Centers of Excellence network facilities. https://www.va.gov/MS/veterans/find_a_clinic/index_clinics.asp. Updated February 26, 2020. Accessed March 6, 2020.

2. National MS Society. MS navigator program. https://www.nationalmssociety.org/For-Professionals/Clinical-Care/MS-Navigator-Program. Accessed March 6, 2020.

3. Wallin MT, Culpepper WJ, Campbell JD, et al. The prevalence of MS in the United States: a population-based estimate using health claims data. Neurology. 2019;92:e1029-e1040.

4. GBD 2016 Multiple Sclerosis Collaborators. Global, regional, and national burden of multiple sclerosis 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18(3):269-285.

5. GBD 2016 Neurology Collaborators. Global, regional, and national burden of neurological disorders, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019;18(5):459-480.

6. Solomon AJ, Bourdette DN, Cross AH, et al. The contemporary spectrum of multiple sclerosis misdiagnosis: a multicenter study. Neurology. 2016;87(13):1393-1399.

7. Spain R, Powers K, Murchison C, et al. Lipoic acid in secondary progressive MS: a randomized controlled pilot trial. Neurol Neuroimmunol Neuroinflamm. 2017;4(5):e374.

8. Martini DN, Zeeboer E, Hildebrand A, Fling BW, Hugos CL, Cameron MH. ADSTEP: preliminary investigation of a multicomponent walking aid program in people with multiple sclerosis. Arch Phys Med Rehabil. 2018;99(10):2050-2058.

9. Turner AP, Hartoonian N, Sloan AP, et al. Improving fatigue and depression in individuals with multiple sclerosis using telephone-administered physical activity counseling. J Consult Clin Psychol. 2016;84(4):297-309.

10. Haselkorn JK, Hughes C, Rae-Grant A, et al. Summary of comprehensive systematic review: rehabilitation in multiple sclerosis: Report of the Guideline Development, Dissemination, and Implementation Subcommittee of the American Academy of Neurology. Neurology. 2015;85(21):1896-1903.

11. Hirsh AT, Turner AP, Ehde DM, Haselkorn JK. Prevalence and impact of pain in multiple sclerosis: physical and psychologic contributors. Arch Phys Med Rehabil. 2009;90(4):646-651.

12. Khurana SR, Bamer AM, Turner AP, et al. The prevalence of overweight and obesity in veterans with multiple sclerosis. Am J Phys Med Rehabil. 2009;88(2):83-91.

13. Turner AP, Kivlahan DR, Kazis LE, Haselkorn JK. Smoking among veterans with multiple sclerosis: prevalence correlates, quit attempts, and unmet need for services. Arch Phys Med Rehabil. 2007;88(11):1394-1399.

14. Turner AP, Hawkins EJ, Haselkorn JK, Kivlahan DR. Alcohol misuse and multiple sclerosis. Arch Phys Med Rehabil. 2009;90(5):842-848.

15. Turner AP, Kivlahan DR, Haselkorn JK. Exercise and quality of life among people with multiple sclerosis: looking beyond physical functioning to mental health and participation in life. Arch Phys Med Rehabil. 2009;90(3):420-428.

16. Turner AP, Chapko MK, Yanez D, et al. Access to multiple sclerosis specialty care. PM R. 2013;5(12):1044-1050.

17. Gromisch ES, Turner AP, Leipertz SL, Beauvais J, Haselkorn JK. Risk factors for suboptimal medication adherence in persons with multiple sclerosis: development of an electronic health record-based explanatory model for disease-modifying therapy use [published online ahead of print, 2019 Dec 3]. Arch Phys Med Rehabil. 2019;S0003-9993(19)31430-3143.

18. Settle JR, Maloni H, Bedra M, Finkelstein J, Zhan M, Wallin M. Monitoring medication adherence in multiple sclerosis using a novel web-based tool. J Telemed Telecare. 2016;22:225-233.

19. Gromisch ES, Turner AP, Leipertz SL, Beauvais J, Haselkorn JK. Who is not coming to clinic? A predictive model of excessive missed appointments in persons with multiple sclerosis. Mult Scler Rel Dis. In Press.

The MSCoE advocates for appropriate and safe use of currently available MS disease modifying therapies through collaborations with the VA Pharmacy Benefits Management Service (PBM). The MSCoE partners with PBM to develop and disseminate Criteria For Use, safety, and economic monitoring of the impacts of the MS therapies. The MSCoE also provide national consultation services for complex MS cases, clinical education to VA HCPs, and mentors fellows, residents, and medical students.

The VA provides numerous resources that are not readily available in other health care systems and facilitate the care for patients with chronic diseases, including providing low or no co-pays to patients for MS disease modifying agents and other MS related medications, access to medically necessary adaptive equipment at no charge, the Home Improvement and Structural Alteration (HISA) grant for assistance with safe home ingress and egress, respite care, access to a homemaker/home health aide, and caregiver support programs. Eligible veterans also can access additional resources such as adaptive housing and an automobile grant. The VA also provides substantial hands-on assistance to veterans who are homeless. The clinical team and a veteran with MS can leverage VA resources through the National MS Society (NMSS) Navigator Program as well as other community resources.²

The VHA encourages physical activity and wellness through sports and leisure. Veterans with MS can participate in sports programs and special events, including the National Veterans Wheelchair Games, the National Disabled Veterans Winter Sports Clinic, the National Disabled Veterans TEE (Training, Exposure and Experience) golf tournament, the National Veterans Summer Sports Clinic, the National Veterans Golden Age Games, and the National Veterans Creative Sports Festival. HCPs or veterans who are not sure how to access any of these programs can contact the MSCoE or their local VA social workers.

Research

The primary goal of the MSCoE research core is to conduct clinical, health services, epidemiologic, and basic science research relevant to veterans with MS. The MSCoE serves to enhance collaboration among VAMCs, increase the participation of veterans in research, and provide research mentorship for the next generation of VA MS scientists. MSCoE research is carried out by investigators at the MSCoE and the MS Regional Programs, often in collaboration with investigators at academic institutions. This research is supported by competitive grant awards from a variety of funding agencies including the VA Research and Development Service (R&D) and the NMSS. Results from about 40 research grants in Fiscal Year 2019 were disseminated through 34 peer-reviewed publications, 30 posters, presentations, abstracts, and clinical practice guidelines.

There are many examples of recent high impact MS research performed by MSCoE investigators. For example, MSCoE researchers noted an increase in the estimated prevalence of MS to 1 million individuals in the US, about twice the previously estimated prevalence.^3-5 In addition, a multicenter study highlighted the prevalence of MS misdiagnosis and common confounders for MS.⁶ Other research includes pilot clinical trials evaluating lipoic acid as a potential disease modifying therapy in people with secondary progressive MS and the impact of a multicomponent walking aid selection, fitting, and training program for preventing falls in people with MS.^7,8 Clinical trial also are investigating telehealth counseling to improve physical activity in MS and a systematic review of rehabilitation interventions in MS.^9,10