“Our team functions as one—united by the fundamental experience of caring for people with a disease that involves increasing needs, and an existential element that few other human diseases have.”

Will North, MD


Neurology, Greater Southern Alameda Area


ALS Multidisciplinary Care Teams

Amyotrophic lateral sclerosis (ALS) is a rare disease, but it exacts an incredible toll, not only on those diagnosed with it, but on their caregivers too. This neurodegenerative condition initially causes slurred speech or weakness in an arm or leg. As it progresses, it renders people unable to walk, use their arms, talk and, eventually, to breathe.

Several years ago, Lynda Lam, MD, Will North, MD, and several other TPMG neurologists saw an opportunity to lighten the load for these patients.

It takes many different care specialists, such as a neurologist; nutritionist; registered nurse; social worker; palliative care specialist; and physical, occupational, respiratory, and speech therapists, to help people with ALS manage the progression of their disease. Research demonstrates that being able to access multidisciplinary clinical care helps patients with ALS live significantly longer and with better quality of life.

Drs. Lam and North and their colleagues Aaron Lewis, MD, and Daniel Lavery, MD, established ALS Multidisciplinary Care Teams at KP San Rafael, San Leandro, San Francisco, and Sacramento medical centers, so that all of the approximately 250 ALS patients in KP Northern California would be able to see all the providers they need to see—on the same visit, and in the same exam room.

With this approach, patients visit the medical centers approximately every 3 months, with each visit typically taking from 2-to-4 hours. The teams also partner with a care manager from the ALS Association, who provides additional support and resources from the community. When patients are no longer able to travel to their appointments, video visits are available, in which the whole team, one by one, talks with the patient.

An ALS Multidisciplinary Care Team was recently established at KP San Jose, and plans are underway to create an additional multidisciplinary care team at KP Walnut Creek.

Last year the ALS Association awarded Kaiser Permanente Northern California the 2016 Commitment to Care Award for coordinated, expert care and treatment of people with ALS.