Reducing discrepancies between MS patients' needs and use of healthcare services by applying a transmural care model.

The Dutch healthcare system is effective for patients with acute, uncomplicated health problems but ineffective for patients with complex, chronic health problems such as multiple sclerosis (MS). To tackle these deficits, special working parties and the Dutch Ministry of Health concluded that healthcare professionals from primary and hospital settings should, by mutual agreement, cooperation, and shared responsibility, better coordinate their care and tailor care to meet patients' individual needs. In the Netherlands this approach is called transmural care. A transmural care model for MS (TCMMS) was developed to assist healthcare professionals in different settings cooperate with one another, comprehensively assess the needs of MS patients, and define an integrated care plan for each patient. The overall aim of the TCMMS was to reduce the discrepancies between the patients' needs and use of healthcare services and to test whether the TCMMS is applicable in practice. Outcomes using the TCMMS were measured using Kurtzke's Expanded Disability Status Scale (EDSS), Incapacity Status Scale (ISS), Environmental Status Scale (ESS), and RAND 36-Item Health Survey (RAND-36). In the study period, many different expressed needs were reported. For the total group the expressed needs decreased significantly from 57 needs 5 months before the implementation of the TCMMS to 19 needs at the end of the study. There were no significant changes over time in EDSS, ISS, ESS, and RAND-36. Overall, the TCMMS was applicable to practice and decreased the discrepancies between needs and services.