Helping Older Adult Patients Find the Specialists They Need

Center for Geriatric Medicine connects with National Consultation Service to help older patients with difficult-to-treat conditions

Patients older than 50 who are suffering from a difficult-to-diagnose medical condition or needing multiple specialists or treatments have a new option for management with Cleveland Clinic’s National Consultation Service. First established in 2006, this service now includes a geriatrics arm. The overall service is based in the Department of Internal Medicine and headed up by Daniel Sullivan, MD, while the geriatrics arm is headed by Ardeshir Hashmi, MD, Director of the Center for Geriatric Medicine.

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Improving accessibility

The National Consultation Service was developed to coordinate care for adult patients with multidisciplinary medical problems living outside the greater Cleveland area who don’t have access to the type of comprehensive care offered at Cleveland Clinic.

“In the past, these patients would try to set up appointments with different specialists themselves,” says Dr. Sullivan, “but the proximity of the specialists and timing of visits were difficult to manage and the coordination of the specialists’ efforts were limited or nonexistent. Each specialist might have been doing exactly the right thing for the condition in their domain without realizing that their treatments were at odds with what other specialists were prescribing. We saw this dilemma and decided to create the service.”

Patients can be referred by a physician or they can self-refer. The patient’s information is taken over the phone and reviewed by a nurse, who then passes the case on to one of the four “quarterback” physicians working on the service. Now, Dr. Hashmi serves as the quarterback physician if the patient is over the age of 50. He can then develop a plan of action and recommend specialists for the patient to see.

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Next, patients come to Cleveland Clinic for a two- to four-day visit, which begins with an evaluation and physical examination by the quarterbacking physician. “We coordinate appointments with specialists, review the results and see patients at the end of the visit to summarize what has been learned and ensure follow-up care and consultation,” Dr. Sullivan explains.

The quarterbacking physicians on the service continue to stay in touch with referring physicians and patients after they leave Cleveland Clinic, acting as a go-between between the community doctors and the specialists, and they may perform follow-up virtual visits with patients if necessary.

Emergence of the Geriatrics Arm

In December 2018, Dr. Hashmi came onto the National Consultation Service to manage the needs of geriatric patients. “The biggest issues we see in this population involves memory impairment and polypharmacy,” he says, “as well as concerns about balance and recurrent falls, normal aging versus potential pathology and mental health issues such as depression and anxiety.”

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In the case of older patients with cognitive impairment, conditions outside of the brain may be causing memory problems—conditions that are eminently treatable. “These patients may have been diagnosed with dementia, when in reality they have a problem like obstructive sleep apnea that is depriving the brain of oxygen and resulting in memory loss,” he says. Alternatively, they may be suffering from depression, which has been linked to memory impairment. They may have reversible vitamin B12 or thyroid deficiencies. Or patients may be using over-the-counter sleep medications or anticholinergics that impair memory. “Once they come off of these medications, their memory often rebounds,” Dr. Hashmi reports.

“Basically, my job as the geriatrician on the National Consultation Service is to connect the dots for older patients and figure out what might be causing their symptoms,” says Dr. Hashmi. “I can then help them find customized treatments that might only be offered here at the Cleveland Clinic and coordinate their care.”

Dr. Sullivan notes that in addition to raising awareness of the program among referring physicians and patients, Cleveland Clinic is hoping to encourage health insurers to look into the service. “These companies may be insuring patients who have been on diagnostic odysseys, where they are being tested and evaluated by a variety of clinicians without identifying a definitive diagnosis or resolving their symptoms, and this may be a more cost-effective option for assessment and treatment.”