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Hospitals Re-Think Neurological Services to Meet Geriatric Needs

Joe Cantlupe, for HealthLeaders Media, April 5, 2013

Success key No. 1: Coordinated care

To improve its neurological programs, especially for those in the geriatric community, the Cleveland Clinic—with a main campus in Cleveland, eight community hospitals, and other facilities—coordinated care among its hospitals, pinpointing demographic needs and expertise in specific areas as it braced for continued demand. In one hospital, Cleveland Clinic added more Parkinson's disease experts and in another boosted the number of available Alzheimer's specialists. The clinic designated its main hospital as a hub for neurological specialties.

"We populate the region with complementary skill sets in each geographic area," says Samples. That expertise is focused on categories such as peripheral nerve and movement disorders as well as stroke. The communities served by the 46-bed Euclid and 35-bed Lakewood rehabilitation hospitals are areas on which to put geriatric and neurological focus, Samples says. For instance, there are two Parkinson's experts at Euclid, and another who specializes in movement disorders at Lakewood. They work at the suburban hospitals and also coordinate care with the main campus. "We are developing a matrix so we get coverage with specific disease disorders," Samples says.

The hospital's internal neurological scorecard shows that it has made dramatic improvements in areas of cognitive behavior, Alzheimer's disease, as well as other afflictions impacting geriatric patients who have neurological ailments. In a review of 3,000 Alzheimer's patients between October 2010 and December 2012, the coordinated care resulted in improvements in mood, sleep, and appetite; additional data shows reduced fatigue among 49% of patients in a one-year-period, which hospital officials characterized as significant. In addition, PHQ-9 scores, a measurement for assessing mental health, improved in 60% of patients with Parkinson's disease. The PHQ-9 is a nine-item scale of the Patient Health Questionnaire, a tool for assisting primary care clinicians to monitor depression and select treatments.

Coordinating care among its hospitals and the main campus has been particularly important while the Cleveland Clinic system faces a paradox, Samples adds, citing increasing demand in the wake of funding cutbacks and anticipated physician shortages in neurological care.

Fewer medical students are choosing neurology, leading to potential workforce shortages, according to the American Academy of Neurology. The organization estimates there are 18,000 Americans for every neurologist, but by 2020, there will be only one neurologist for every 21,000 in the United States. Beyond that, a "shortage of well-trained neurologists to train an increasing number of neurological physicians" is projected in an AAN report, The Critical Role of Neurologists in Our Health Care System.

To address those potential shortfalls, the Cleveland Clinic is focusing on increased use of midlevel providers and nurse practitioners specializing in neurological care; psychologists, social workers, and counselors are also used in the geriatric neurology program.

Success key No. 2: The geriatric ED

At UH Regional Hospitals, Bedford and Richmond Medical Center campuses, the special geriatric ED—dubbed the Senior ER—includes senior-friendly amenities and specially trained clinical staff. The unit's personnel receive extensive training to better recognize and treat acute and chronic medical conditions specific to the geriatric population. Before the hospital initiated the senior ER, it found that at least 54% of ED visits involved people over the age of 65, according to Delgado. The changes have led to a 30% reduction in the number of people in that age range who have returned to the ED within 72 hours of their previous visit.

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