This article appears in the March 2013 issue of HealthLeaders magazine.
Six years ago, the 1,239-bed Cleveland Clinic began to systematically take on one of the biggest challenges looming in healthcare: an increasing aging patient population that needs neurological care.
In 2007, the Cleveland Clinic in Ohio had only "a handful of neurologists in our regional hospitals" who treated perhaps 1,000 elderly patients with neurological conditions a year, recalls Stephen Samples, MD, vice chairman of the Cleveland Clinic's Neurological Institute. By 2012, he says that number grew to 38 physicians overseeing the care of 52,000 patients, reflecting the urgently expanding needs in neurological care, especially in geriatric medicine.
At the Cleveland Clinic and other facilities around the country, the burgeoning 65-and-older population is expected to drive up the number of neurological geriatric patients, increasing volumes in hospitals that focus on complex conditions, with subspecialties targeting dementia and other cognitive disorders. Programs aimed at older people with such disorders, or those afflicted with Alzheimer's or Parkinson's disease, are expected to grow dramatically as the country ages.
Some hospitals are ramping up their care planning with specialized clinics in neurological institutes and changing their specialties to meet the demographic needs of their aging communities. In other cases, hospitals are using holistic approaches to care, emphasizing multidisciplinary programs to improve education and rehabilitation programs for patients to address their debilitating conditions.
"We already know that neuroscience has a predominant geriatric flavor," says Samples. "We firmly believe that neurology is not one specialty, but different specialties, like Parkinson's disease, dementia, spinal disease, dizziness, and balance problems. In the next 10 to 15 years, neurological care would be for each disease process, like how there are now different specialties for cardiology care, which was all considered internal medicine years ago."
The need for geriatric care in neurology is blossoming. About 5.4 million people have Alzheimer's disease, and most of that, 5.2 million, represents those 65 and older. The dire consequences of these illnesses give medical centers financial headaches of their own. "We're not making money; we're trying to reduce the cost of care for that patient population," says Deborah Spielman, assistant vice president of Florida Hospital and administrator of the Florida Hospital Neuroscience Institute in Orlando, part of the 2,247-bed Florida Hospital system that has acute care facilities in Orlando, Tampa, and Daytona Beach.
While hospitals must brace for a growing number of patients, reduced reimbursements and shortages of neurologists and geriatric physicians are forcing them to be innovative in their care. That, in turn, is prompting hospitals to initiate changes in their care models to avoid needless or more expensive programs, says Spielman. Focusing on geriatric neurological ailments, the hospital established a Maturing Minds Clinic adjacent to its 120-bed neurological facility in Orlando. There, physicians can evaluate conditions and work toward avoiding hospitalizations of neurological geriatric patients, who can be cared for through alternative programs. "More and more, the adult children are at their wits' end, and we feel it's our obligation to offer comprehensive programs," Spielman says.
Hospitals are refocusing on geriatric neurological conditions to ease the strain on other parts of their operations, such as the emergency department, says Laurie Delgado, president of Cleveland-based 101-bed total UH Regional Hospitals, Bedford and Richmond Medical Center campuses. In that way, the Ohio health system organized a specialized "senior" ED within its main ED to accommodate patients who have dementia or Alzheimer's disease, she says.
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.
Patients receive clinical assessment within 30 minutes and have 24-hour access to physicians and nurses trained in senior care. One of the most important elements in the care for geriatric patients is having a pharmacist working with the ED staff, which enables staff to coordinate with patients and their families to "provide education as needed and get them into physical therapy if need be," says Howard Dickey-White, MD, the president of University Emergency Specialists and a UH Regional Hospitals ED physician. He says it was important that the hospital not only deal with the presenting emergency issue, but also with the chronic medical conditions and social needs.
The patients are screened for depression, dementia, delirium, or functional decline, and the hospital refers social services, if needed, for psychological concerns. The evaluation includes medication reviews, especially for those who have experienced falls or a sudden acute mental status change. There are also evaluations for potential abuse or neglect. The hospital works with a caregiver to ensure safe transition to home or other healthcare facilities.
"We really felt we had an opportunity and responsibility for due diligence to see what we could do to elevate care. It was not that much of a stretch to see that the Senior ER can be a life-changing event. Often, it was confusing the patients to navigate the system," Delgado says.
"When we have the assessment, the additional risks can be identified, such as dementia and depression and those sorts of things," she adds.
As part of the evaluation and screening for geriatric syndromes such as depression, dementia, or functional decline, the hospitals hire nurses who have designation as Nurses Improving Care for Healthsystem Elders. These professionals are trained to address the challenges of elderly patients in acute care hospitals. The NICHE program is based at the NYU College of Nursing and involves almost 450 hospitals and healthcare facilities.
Success key No. 3: Maturing Minds Clinic
A growing elderly population is virtually a constant in Florida, and at Florida Hospital, leaders are working to unravel some of the mysteries of dementia to reduce readmissions and emergency department use.
Through its Maturing Minds Clinic, the hospital evaluates elderly patients who may have had a misdiagnosis of dementia. The hospital has enrolled at least 100 elderly patients in the program, which uses a multidisciplinary team to assess patient needs. Specifically, patients are evaluated for normal pressure hydrocephalus, which has symptoms similar to dementia but can be reversed with appropriate treatment.
An estimated 375,000 Americans are misdiagnosed with dementia or Parkinson's disease, yet have symptoms caused by NPH. Florida Hospital officials estimate as many as 10% of patients who are diagnosed with dementia may have NPH.
"Some of those symptoms actually mimic dementia symptoms," says Spielman. "If you don't evaluate for it, which can include an MRI or other testing, you may not know what it is. It was important to have a fully integrated team, including neurology specialists in rehab, surgery, neuroradiology, neuropsychology, and nursing." Each member "does a full assessment from his or her specialty standpoint on these patients."
The NPH condition occurs when cerebrospinal fluid accumulates in the brain without a significant increase in pressure. The accumulation may lead to the slow onset and progression of symptoms. Because of the difficulty in diagnosis, it is often untreated for extended periods.
Florida Hospital officials say they want to identify NPH patients who may benefit from the placement of a stent to reduce inpatient admissions and avoid potential ED visits. The hospital also wants to increase knowledge and treatment of NPH through evaluations.
A University of Florida analysis shows that patients with Parkinson's disease are 50% more likely to visit an ED than those who do not have the disease. Often, they are treated because of ancillary issues such as urinary tract infection, pneumonia, and heart failure, according to the National Parkinson Foundation.
Florida Hospital officials say that patients with Alzheimer's are readmitted to hospitals more often than other patients. "We have looked at our data, and patients with a primary or secondary diagnosis of Alzheimer's have almost a 10% higher chance of being readmitted to the hospital multiple times," Spielman says. "The change in mental status, many times caused by other medical conditions such as UTI or pneumonia, continues to bring them in over and over.
"So much crossover occurs in this particular population, and so many things can be going on: What's causing the illness?" Spielman asks. "They may have multiple readmissions. They are not coming back necessarily because of dementia, but because of congestive heart failure. It's not the ideal situation if they have dementia or Alzheimer's. They end up staying twice as long, in some cases, as somebody else. Their condition requires a special communication style, a special approach. It's case management on steroids for this subset of Medicare patients, and we are trying to keep them out of the hospital for avoidable medical conditions."
For dementia patients, it's a case of issues on top of issues—from medication complexities to pulmonary complications and urinary tract issues—which compounds the readmission quandary.
In the latest Hospital Compare reports from 2012, Florida Hospital had a 27.3% readmission rate for 3,666 heart failure patients, compared to the national average of 24.7%. The hospital also had a 20.7% readmission rate for 2,223 pneumonia patients, compared to 18.5% for the national average. Readmission for elderly patients is more complicated because of their array of conditions.
Success key No. 4: Outpatient programs
Parkinson's disease, a progressive disorder of the nervous system, affects a patient's movement, balance, speech, fine motor skills, thinking, and behavior. In the United States, up to 60,000 cases of Parkinson's are diagnosed each year, and 1 million people currently have it. While the disease can't be cured, a combination of medications, therapy, and other programs reduce the symptoms—as does surgery.
The 60-bed Spaulding Rehabilitation Hospital Cape Cod in East Sandwich, Mass., utilizes a holistic approach that includes medication management. Spaulding's solution consists of timely rehabilitation and coordinated care using neuro-rehab specialists, says David Lowell, MD, CMO at Spaulding's Centers for Geriatric Neurology. Through a combination of outpatient and inpatient treatment approaches, elderly Parkinson's patients have been able to extend the time they are able to live at home on average 1.5 more years, instead of needing to live in an assisted living or skilled nursing facility, Lowell says.
The Centers for Geriatric Neurology are part of the Spaulding Rehabilitation Network, which is part of Partners HealthCare System based in Boston. When they opened in 2010, the centers served 62 patients. In 2012, they admitted 124 new patients, Lowell says.
What began as the Parkinson's Center for Comprehensive Care expanded to also include care for stroke, gait disorders, and cognitive disorders. Lowell says the centers' rehab model offers functional and holistic therapies along with medical management.
Such programs may seem simple, but they are important for patients. During patient visits, hospital staff may adjust devices, carry out gait training, make suggestions for improved mobility, adjust medications, and even advise on changing pajamas—such as from fleece PJs to those with silk liners—to improve movement. These are "little tips we can provide," says Dawn Lucier, neuro-rehab physical therapist.
"It's different from the standard medical model," Lowell adds. "Typically, the person says, 'I've fallen twice,' and the doc would write a prescription for a physical therapy evaluation and send the patient to the therapist, who would then do an evaluation and develop a treatment program. We're actually watching the people and seeing what's wrong with their gait and then developing an individualized plan of action. Sometimes it doesn't require a physical therapy evaluation; it's something simple, like a reminder for them about how to walk with the walker and adjusting the walker."
The hospital continually works to reduce fall rates and bedsores among patients, Lowell says. Over the past year, the hospital fall rate was reported at 4.12 falls per 1,000 patients, compared to peer groups statewide that had 4.64, according to PatientCareLink, a quality and transparency collaborative established by the Massachusetts Hospital Association and the Organization of Nurse Leaders, MA-RI. The rate was calculated from April 2011 to March 2012. Patients having falls with injuries were calculated slightly higher at Spaulding, at 0.84 per 1,000 patients, compared to 0.78 among other rehab facilities. Those injuries are described "very broadly" to include a bruise or scrape, say Spaulding officials.
Pressure ulcers were reported at zero per 1,000 patients at Spaulding Cape Cod, compared to 0.65 per 1,000 patients for the reporting periods of June, September, and December 2011 and March 2012. Lowell attributes Spaulding's rounding program as a key reason for both reductions in falls and reduced bedsores. Spaulding started a nurse rounding program that "quickly evolved into a multidisciplinary" rounding program, Lowell says. The rounding occurs hourly during the day and every two hours at night. At that time, a member of either the nursing or therapy staff checks the patient and reviews key indicators that have a high correlation to quality, including the need for toileting, changing of position, and medications.
"We know that improvements in strength, balance, and endurance help people regain their footing if they should be caught off balance. The education we do around safety and mobility also helps people avoid potentially challenging circumstances at home and in the community," Lucier says.
Officials see the wellness program as an integral part of improving patient care, especially those with Parkinson's disease. Spaulding Rehabilitation Hospital's Cape Cod outpatient centers in Sandwich and Framingham, in partnership with Boston University's Sargent College of Health & Rehabilitation Services, runs the Parkinson's Disease Wellness and Exercise Program.
Participants learn exercises and also a problem-solving approach to manage daily mobility, self-care, and communication issues. The program addresses issues such as balance, strategies to facilitate self-care, improving volume of speech, and conserving energy.
The results of testing 17 patients in the most recent group in 2012 showed significant milestones of success for the geriatric patients, she adds. Fourteen of the 17 patients who completed the six-minute walk test showed improvement in distance. All of the 16 patients who completed the functional gait assessment, which assesses balancing during turning and stepping over obstacles, showed improvement.
Expanding care for the growing population with neurological needs will require innovation and creativity, as programs must be tailored to a wide array of symptoms, causes, and impacts. Watching some of the "best in class" medical centers adapt to the demographic demands of the neurological service line landscape will pave the way for other hospitals looking to do the same.
Joe Cantlupe is senior editor for physicians and service lines. He may be contacted at jcantlupe@healthleadersmedia.com.
Reprint HLR0313-7
This article appears in the March 2013 issue of HealthLeaders magazine.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
