Multidisciplinary chronic disease management

My daring idea for health care in Alberta

June 5, 2017

Jacqueline Bakker, MD, FRCPC (Neurology), BscPT

Contributed by: Jacqueline Bakker, MD, FRCPC (Neurology), BscPT

Treating those who suffer from chronic disease has unique challenges. I practice as a neurologist specializing in multiple sclerosis (MS), a chronic neurologic disease that cannot be fixed or cured at this time. It can only be managed. Unfortunately, despite various therapies, the disease will progress. Each patient’s disease course is unpredictable as are the person’s medical needs. It is difficult to manage these patients effectively in a private office with only a physician and an administrative assistant. In an ideal medical world, we would have the resources we need at our fingertips and unlimited funds to support those resources. In our real medical world, however, these are not available. There are positives to this, however: the situation allows patients to be self-motivated and self-directed in their own care.

It is important for patients to be involved with and take charge of their medical concerns, with some guidance. This control may mean booking or waiting for appointments, arranging transportation and having the motivation to participate. But it ultimately gives the patients responsibility.

In the MS Clinic in Red Deer, we are fortunate to practice in a medical specialty clinic that shares multidisciplinary resources such as nurses, occupational therapists, dieticians and social workers. We have access through referral to physiotherapy, speech pathology and pharmacists, and we refer patients to the MS Society for social support. The goal of the MS Clinic is to promote the well-being of the patients and encourage them to direct their overall care.

At one appointment, an MS patient’s medical, psychosocial, functional, nutritional and educational needs can be managed. The patient sees the physician for medical assessment. An MS-specialized nurse provides education, deals with managing any medication side effects, deals with any bladder and bowel control issues through conservative strategies and allows for subsequent follow up over the phone to see if the patient is managing with the medical plan.

If the patient has issues with daily living such as fatigue, managing job or school work, dressing, eating, driving, or cognitive problems, these issues can be assessed and assisted by our occupational therapist. If a patient has questions and concerns regarding disability, housing or counselling, our social worker can help with appropriate paper work and/or suggest appropriate resources. Our dietician sees any patient who has dietary concerns.

A major hole in our immediate team approach is mental health. Many of our patients have anxiety, depression and stress that are accentuated by the diagnosis of a chronic unpredictable disease. And they need help working through these emotions. Whether dealing with a new diagnosis or navigating through family stressors influenced by their disease, patients sometimes have nowhere to turn. Although we can refer these patients to outside resources, these are limited and the wait time is often long.

By working with a team that can offer multidisciplinary resources, patients feel they have accessible resources if and when they have questions or new medical issues. Through this approach, I believe we reduce hospital visits and allow for better quality of life for the patients and their families or caregivers.

The Alberta Medical Association stands as an advocate for its physician members, providing leadership & support for their role in the provision of quality health care.