National Consultation Service Fast-Tracks Multispecialty Evaluations

Imagine a patient with multiple medical problems who sees several specialists, but whose condition remains undiagnosed, or who is not responding to treatment, even after careful assessment and extensive investigations — or perhaps a patient whose care needs coordination among multiple specialists and for whom the process of care has become, or may become, very prolonged and fragmented.

In such cases, physicians and patients across the nation can turn to Cleveland Clinic’s National Consultation Service for help.

The service, based in the Department of Internal Medicine at Cleveland Clinic’s main campus, offers self-referred patients and referring physicians the opportunity to access top experts among Cleveland Clinic’s more than 500 physicians within a few-day visit to Cleveland, all choreographed by a dedicated internist who “serves as the quarterback,” according to Cleveland Clinic internist Stephen Hayden, MD.

Coordinated, comprehensive evaluations

Cleveland Clinic’s National Consultation Service draws patients from Ohio and surrounding states, and occasionally from as far away as Alaska and Hawaii, for a rapid-pace series of evaluations by relevant specialists.

Many regions do not have the medical resources to allow for such a comprehensive and coordinated multispecialty evaluation, so patients are willing to travel “because Cleveland Clinic has a great number of highly qualified specialists who really know their topics in great detail, and in many cases are highly subspecialized within their specialties,” explains Dr. Hayden.

The service often helps patients with chronic conditions that require the engagement of multiple specialists, and those for whom a definitive diagnosis remains elusive, as well as patients who have highly specialized needs and rare conditions. Often patients have attempted to manage their own care which can lead to inappropriate assessments and treatment, and this service can be very helpful in redirecting treatment. When care is not physician-coordinated, it can easily extend weeks or longer and ultimately leave a patient without concrete answers or a defined course of treatment. The service is designed to avoid this by ensuring that an internal medicine specialist is providing coordination of care.

Consultation experience

Pre-visit: Physician-referred and self-referred patients may call the appointment number and ask for this service. The National Consultation Service team will then reach out to gather information about the reason for the visit, which the patient is asked to submit in a short description by electronic record, fax or mail or by a telephone call with a dedicated registered nurse. Physicians can also write or fax requests for consultation. The National Consultation Service physicians are happy to discuss potential referrals directly with referring physicians.

The information about the patient’s reasons for the assessment is reviewed by a physician and used to plan what consultations are likely to be beneficial and to determine whether records should be sent in advance or brought by the patient to the initial appointment. Typically, consultations are then prescheduled in a two- to four-day block.

Two- to four-day visit: The in-person visit begins with an in-depth (80-minute) internal medicine physician assessment. The patient then proceeds to the specialist consultations that have been scheduled in advance. If any additional tests or consultations are needed, they are scheduled at that time. The coordinating internist then receives the specialist reports, corresponds with the team via the electronic medical record and by phone when needed, and prepares a specific step-by-step treatment action plan for the patient to take home. The findings and treatment plan are discussed at the patient’s final appointment with the National Consultation Service physician during the patient’s Cleveland stay. This report visit typically lasts 20 minutes to an hour to ensure the patient has a full understanding of the evaluations and recommendations.

Outcome: During the final report visit, the patient leaves with next steps clearly outlined and pertinent orders or reports to share with hometown specialists or primary care providers. While many patients self-refer, Dr. Hayden notes it is beneficial and preferable for the Consultation Service internist to coordinate with a primary care or other referring physician who will help the patient see through the treatment plan next steps as recommended by Cleveland Clinic. These may include new treatment approaches, additional procedures or laboratory test follow-up, or imaging that could not be done while the patient was in Cleveland.

Follow-up communication regarding the outcome of any follow-up tests is managed by phone and electronically.

The intention is to provide a plan that can be carried out in the patient’s hometown in the long run, under the supervision of the patient’s local physicians, but some specialized testing or treatment can require additional visits to Cleveland Clinic. Referring physicians can, with the patient’s permission, access the Cleveland Clinic medical record through Epic Care Everywhere and the DrConnect® service at clevelandclinic.org/drconnect.

Coordination is key

“The greatest advantage for patients is coordination,” says Dr. Hayden. “If you have a patient who has a number of different medical problems, has seen numerous physicians and had a lot of tests, and hasn’t gotten the answer or a plan of care that works for him or her, we are a good resource for putting that together.”