Neuroscience: Growing Beyond Stroke Care

Hospitals and health systems are relying on partnerships and patients to improve care coordination and build opportunities for sustainable growth in the neuroscience service line.

This article first appeared in the April 2016 issue of HealthLeaders magazine.

While stroke care remains one of the top priorities of the neuroscience service line, there is still plenty of room for growth in this specialty beyond achieving the designation of a primary stroke center. Healthcare executives are looking for ways to improve care coordination for their neuroscience patients.

Some health systems, such as Palo Alto, California–based Stanford Health Care, which is part of Stanford University Medical Center, have thrown out the old siloed playbook and now have all of their outpatient neuroscience services under one roof. Other hospitals, such as the standalone 296-bed Silver Cross Hospital in New Lenox, Illinois, are partnering with larger systems to leverage access to specialty care for patients. Both strategies signal a new chapter for both patients and providers.

Success key No. 1: Centrally locate outpatient services
When Stanford Health Care's new $80 million, five-story Neuroscience Health Center opened on January 11, there were 246 patient appointments on the schedule. For Stanford Health Care executives Frank Longo, MD, PhD, chairman of the department of neurology and neurological sciences, and Alison Kerr, vice president for operations, that first day was a test. Over the course of that first 12-hour day, they would find out if five years of planning, building, and designing a new one-stop shop for outpatient neuroscience services truly met their patients' needs.

"I got an email from a patient who has been to many of our clinics," Longo says. "Her email started off with capital letters: WOW." Longo says the patient wrote that she "couldn't believe" all that the building had to offer.

That wow factor was possible because of 12 patients on the neuroscience patient advisory council who played a major role in the building's design. "They are our subject matter experts; our clinicians are not," Kerr says. "These are people with Parkinson's and patients who have had aneurysms, brain tumors. How can you argue with somebody who has had a stroke that says, 'I'm going to slip and fall on that floor.' You can't argue with someone's day-to-day experience."

The hands-on work of the neuroscience patients led to wider hallways and exam rooms to accommodate electric wheelchairs and additional caregivers who accompany patients to appointments. Lighting and building acoustics were designed to accommodate patients, as well. No detail was left to chance. Picking out the right chairs for the waiting room took an entire day because patients reported that people who have spinal rods can't sit low and need additional support on the seat. "There are some really important things our patients told us that we would not have known," says Kerr. "We would have designed a standard office building with waiting room space."

Paint colors, carpet nap, and lighting were chosen with patients because of their firsthand experience, but it is the new "hallway conversations" and care coordination opportunities that clinicians are most excited about.

The center is meant to be a comprehensive outpatient center that reduces the number of appointments for neuroscience patients by using a team-based approach to care. "The only thing that was in one location before this center was our clinics," Kerr says. "We made our patients seek out our services, but we've flipped that model and now all of us circle the patients in one building."

The new center houses 21 neuroscience subspecialties, imaging, neuro-rehabilitation services, and physical and occupational therapies, which Longo says leads to more collaboration. "One situation we're commonly in is that a patient will have some features of a movement disorder, such as Parkinson's, and some features of a dementia, such as Alzheimer's, and we want to show this to a colleague," Longo says. "I can't describe the patient or tremor over the phone. In the old model, the patient would have to make a separate appointment and come back to our movement disorders clinic. Now I can walk over to one of our eight movement disorder neurologists and say, 'Hey, can you come and eyeball this patient?' Even if it's just for a minute, it's so much more efficient."

The new center, says Kerr, is poised to handle the growth of its neuroscience ambulatory visits, which has ranged from 15% to 20% per year since 2013 when its patient volume was 35,000 annually. Kerr says neuroscience is on the cusp of an innovation bell curve.

"We understand risk factors for cardiovascular disease, we've got lipids, we've got statins, but we don't understand Alzheimer's," says Kerr. "There is a partnership with our physician and neuro scientists at Stanford, and we eagerly anticipate many new discoveries and treatments."

Stanford's new center also connects patients to cutting-edge research. "When a patient has been affected with a neurological disorder that doesn't have an easy cure, having access to the research is so important, and a traditional clinic space is not built to support research activities for the patients, families, and physicians. We have space dedicated to make research access easy and efficient," says Longo, referring to the Alzheimer's Disease Research Center that is funded by the National Institutes of Health.

Success key No. 2: Partner for specialty care
Stanford Health Care's resources are enviable. Smaller hospitals that have patients with the same needs may not have easy access to an academic medical center or a large, integrated system. One solution is to merge with a larger organization, but Silver Cross Hospital, a 296-staffed-bed community hospital outside of Chicago, has resisted that trend and instead aggressively pursued affiliations with organizations that could bring their expertise to the suburbs.

"We have five partners, and every year we meet with the board to review them," says President and CEO Paul Pawlak.

Silver Cross' journey to tracking down partners began in 2009, with the Rehabilitation Institute of Chicago and rehab services. It was a weakness at Silver Cross, with only 305 patients per year. Now, patient volume is nearly doubled to 604 patients annually, he says.

Pawlak set out to similarly improve Silver Cross' neuroscience service line because he wanted the hospital to be a primary stroke center. Earlier efforts to develop neuroscience in the 1990s fell apart, he says.

Two things happened in 2012 that made a partnership to grow a neuroscience service line possible. First, Silver Cross built a new $365 million hospital in a new location in New Lenox. Second, a neuro-interventional radiologist—Harish Shownkeen, MD, at Cadence Health, which is now part of Northwestern Medicine, the health system that includes 1,500 employed physicians, an academic medical center, and outpatient clinics in metropolitan Chicago—needed space to practice. "Shownkeen reached out to us," Pawlak says.

The partnership between Cadence and Silver Cross meant that Pawlak would build an endovascular neuroradiology lab that would be staffed full-time by Cadence neurointerventional radiologists and neurologists. There are now five neurologists and also three neurointerventional radiologists. "I knew what we were doing was so important to our community," Pawlak says. "It meant that people who were suffering from a stroke didn't have to travel."

Still, the effort was not enough to generate substantial patient volume in the first year. Pawlak says transfer agreements from hospitals were more difficult than expected, and recruiting staff for the new neuro lab at Silver Cross was hard. "We needed to recruit radiology techs with experience working with the brain," he says. "Those people are hard to find, and it took another one and a half years for sustainability."

Given the slow start of the program, financial arrangements of the partnership with Northwest Medicine had to be modified. But, Pawlak says, it reinforced the need to be nimble and adapt. "Each service line is different," he says. "We have to bend and be flexible."

To improve volume, Shownkeen and Ruth Colby, Silver Cross' chief strategy officer and senior vice president of business development, hit the road, visiting emergency departments and neurology groups to show what Silver Cross could now offer. Shownkeen also put together an annual conference offering CME credits. Pawlak says 400–500 people show up. "It's another way of letting the community know what we can do. He is masterful at including other physicians."

The effort is paying off. In its first year of operation, Colby says Silver Cross had 105 patients in its new lab. Volume has now doubled and is continuing to grow. Silver Cross has also since earned primary stroke certification.

Another byproduct of a partnership strategy is that Silver Cross does not employ many physicians. "We only employ 10 doctors," Pawlak says. That approach, he says, attracts the physicians who want to remain independent but still have access to expert programs in the primary hospital.

Colby's advice to hospital executives is straightforward: Know your weaknesses; don't ignore them. "We felt we weren't the best in certain areas, such as oncology, neuroscience, and rehabilitation," she says. "If you can't be the best on your own, then bring someone in."