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The Transmural MS team: NMSC’s daring move to improve the experience of Multiple Sclerosis patients 

Specialized in Multiple Sclerosis treatments in Belgium, the National MS Center (NMSC) took a bold move in 2015 after identifying the need to provide specific answers to recently diagnosed MS patients. By gathering a multidisciplinary team offering support to patients both inside and outside their facilities, they created a unique program – The Transmural MS team – that drastically improved patience experience.  

After 7 years of hard work, the initiative caught the attention of PX experts and won the 2022 SPX Awards. Back to the genesis of the Transmural team initiative and how winning this award boosted their confidence to keep on breaking down barriers.  

A direct response to the need of long-term treatment plans for younger patients

Gertie Dalemans, Head Coordinator of the Transmural MS Team at NMSC, explains that in the past there were no tailor-made services or specialized therapies for the group of MS patients who were recently diagnosed with MS. Physicians and therapists at NMSC saw that the questions and needs of this group of people were of a different nature than those who had been diagnosed with MS a longer time ago. They reflected on the type of problems that (young) people who are diagnosed with MS have to deal with, such as the kind of guidance they needed, and the problems and concerns in the early stages of this disease. 

As a response, physicians, therapists and MS nurses set up the Transmural MS Team (TMST) in 2015. The goal was to provide long-term guidance for people who are newly diagnosed with MS and their relatives, on medical, allied healthcare, psychological and social levels, both inside and beyond the walls of the NMSC. 

Today, TMST provides long-term biopsychosocial support for people with MS (pwMS) who currently do not require an intensive rehabilitation programme or permanent care. This multidisciplinary team offers a care framework based on the most relevant domains in MS rehabilitation, starting on day 1 and running throughout the patient’s disease course.  

An unparalleled impact on MS patients’ daily lives 

The basic principle of the programme is the timely provision of expertise to MS patients through the different phases of their disease progression by an experienced multidisciplinary expert MS care team, as much as possible in the patients’ own environment. Deploying expertise and guiding people with MS at the earliest possible stage of the disease results in better self-management for the person with MS and – in a number of situations – avoids the need for more intensive guidance, as otherwise people may wait too long before calling in medical and allied health expertise in various domains such as employment, cognition, fatigue and mobility. 

“Thanks to the guidance of TMST, I had sufficient information to talk to my employer about adjusting my work environment. He ended up approving the changes!”

R.S. from Antwerp 

The diversity in the TMST care programmes shows that a lot of effort is being made to encourage people with MS to keep participating in their daily and professional activities. These include a support programme (focused on accepting the diagnosis), a mobility and physical activation programme, and a cognition programme. The team works in a multidisciplinary way and looks for the right individual approach in case of problems, for example with bladder and bowel management, intimacy/sexuality, or the organization of home care. 

 “My fear of ending up in a wheelchair is addressed because I get personal advice on how to train my muscles. Every problem I have is met with an individual solution.”

E.V.W. from West Flanders 

Each programme focuses on maintaining people’s daily structure and preventing people from becoming isolated due to their MS-related problems. Two programmes focus even more specifically on this topic: energy management and employment.  

Broadening the TMST scope across Belgium 

In 2022, 952 unique patients were treated by the Transmural MS Team, representing a total of in 2,496 sessions. If most of these sessions took place in the National MS Center, 30% of the patients underwent a multidisciplinary screening by the Transmural MS Team outside of the NMSC facilities.  

Indeed, since their start in 2015, the TMST has been working on broadening the scope of the programme by establishing partnerships with other facilities. Today, the TMST has partnerships with 12 hospitals spread across Belgium. These partnerships allow collaborative work with neurologists as members of TMST visit them on site. In this way, people with MS and their relatives can receive extensive advice in their own hospital. 

Winner of the SPX Awards 2022

After 7 years of hard work, winning the SPX Awards came as a realisation of the quality of the project developed at NMSC for the team. At the start in 2015, they developed a vision based on their experience, coupled with the feedback from patients with MS. These people were perhaps not yet ready for extensive, intensive guidance, but they already had a lot of questions and fears about the future, and the support available at the time was aimed at pwMS who needed more intensive rehabilitation and help.  

Receiving the award was therefore a first major milestone in this project and a great appreciation for 7 years of hard work according to Gertie Dalemans, Head Coordinator of the TMST.  It has pushed them to increasingly think outside of the box.  

“Winning the award gave us the courage to be more open to the outside world, showcasing even more what benefits we provide. Thanks to the acknowledgement of a neutral external organization such as SPX, we feel that we are taken seriously as a (relatively small) rehabilitation hospital and centre among all the major healthcare players. We realize that we can offer valuable specialized care tailored to our patients. You could say that the award has given us a stronger and more confident position in the market!” 

With this mind, the NMSC was inspired to make a video about TMST with patient testimonials. This video, to be released soon, will not only benefit partner hospitals, but also new candidate hospitals as the centre is looking for new partnerships both in the Brussels region and in Wallonia.  

Finally, winning the SPX Awards was also a great incentive to start thinking about the next phase in the project. A new care programme that can support people with MS even closer to their homes? A coaching approach to help patients identify the journey they want to follow? A method to involve patients in evaluating the programmes? The possibilities are numerous, and the award made them realize that a lot can still be done in the guidance of people with MS, and for that, keeping an open mind, without limitations, is essential. 


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