MS Integrated Care Framework

The MS Integrated Care Project was set up to better understand how people with multiple sclerosis (MS) find and use healthcare in New South Wales. It was funded by NSW Health and led by MS Plus, in partnership with Westmead Hospital.

This project was shaped by people with MS, carers and health professionals. They shared their experiences, highlighted common problems and worked together to suggest solutions. Their input led to a new framework to help improve MS care across the system.

More than 380 people with MS contributed through surveys and focus groups. Health professionals from over seven MS centres also provided input, offering critical insights into workforce pressures, systemic barriers, and service gaps.

The MS Integrated Care Framework has been released, sharing key findings and recommendations to help inform and understand how people with MS navigate and experience their care.

Key findings from the report include:

• Fragmentation places the burden on people with MS. PwMS often coordinate disconnected health, disability, and social supports themselves, relaying information between providers due to siloed communication.
• GP-Neurologist collaboration is beneficial, but is inconsistent. Where collaboration is strong, PwMS feel more supported and confident, report higher satisfaction with neurologist care, better mental health support, and more useful sharing of allied health updates, yet 54% of PwMS felt there was little or no collaboration between their neurologist and GP.
• 44% of PwMS were rarely or never offered emotional or mental support when they requested or clearly needed it.
• 39% of PwMS rarely or never received helpful lifestyle and wellbeing information from either their neurologist or GP.
• MS Nurses are vital to MS care, but not every PwMS has access to this support. MS Nurses provide continuity and extensive non-clinical support, including assistance with NDIS and housing documentation. However access varies by clinic and location, and are at capacity with demanding workloads.
• 1 in 2 PwMS were not fully confident in knowing who to contact when they had new or changing symptoms.

View or download a copy of the MS Integrated Care Framework below.

This project was made possible through the support and partnership of many individuals and organisations dedicated to improving outcomes for people living with MS.