Taking Neurology to the Underserved - A Pilot Initiative in an Urban Homebound Program

Abstract

OBJECTIVE: The objective of this pilot program was to establish a volunteer neurology consult service within the Mount Sinai Visiting Doctors Program(MSVD) in order to address the unmet needs of homebound patients with neurological conditions as well offer a unique educational experience for residents, fellows, and medical students.BACKGROUND: Over 2 million people are homebound in the United States with an increase of 50% expected over the next twenty years. Though home based primary care programs are effective in reducing hospitalizations among this population, they lack subspecialty care. With conditions such as dementia and stroke afflicting a large proportion of homebound patients, neurologic consultation is warranted.DESIGN/METHODS: Neurology consults were requested by primary care providers from MSVD to PGY-3 and PGY-4 Mount Sinai neurology residents and Multiple Sclerosis Fellows. Home visits were conducted by the trainee with Neurology attendings serving as preceptors and providing indirect supervision. Patients were seen throughout Manhattan. Consult findings and recommendations were documented in the electronic medical record.RESULTS: Over three years, 30 home visits were conducted: 29 new consults and 1 follow up. The average age of the patients were 71 years, with female to male ratio of 2:1. 79% were 60 years and older, 48% were white and 28% Hispanic. The most common diseases and conditions consulted on were: parkinsonism, demyelinating disease, stroke, headache, and neuropathy. Three illustrative cases will be presented.CONCLUSIONS: Our pilot program highlights types of chronic neurologic illnesses afflicting the homebound population, treatment interventions utilized, and clinical challenges encountered. By considering the real-world intersection of disease and living environment, trainees gained perspective on the debilitating impact of neurological illness on homebound patients. This pilot program reveals the need and feasibility of neurological home based care as an important clinical, educational, and palliative paradigm.