Options for Chronic Care Management Models in Neurological Care 

Panelists delved into chronic care management advancements, teleconsultations, and operational efficiency tools to support overwhelmed private practice neurologists in a 2025 NeuroNet Pro Annual Summit session.

“I realized a year before her diagnosis, I’d started beating my grandmother at Mario Cart,” said panalist Nikhil Patel. “And she was killer at Mario Cart, she held the neighborhood record for a long time.”

Patel was 11 years old at the time and remembers tell-tale signs of dementia such as decreased ability to do tasks she once excelled at as being early indicators of his grandmother’s declining cognitive abilities.

“I few months later I was playing my grandfather and wondered, ‘Hey, can we use his Mario Cart scores to catch if he is developing Alzheimer disease as well?’ As would be obvious to anyone who isn’t a child, you can’t use Mario Cart scores to predict dementia but that idea for creating a tool stayed with me,” Patel said.

When his grandfather did develop dementia in 2021, Patel graduated college and worked to create a tool for his family to better manage dementia care. That tool became what is now Craniometrix, a dementia care model created at Johns Hopkins that directly informed the new CMS GUIDE Model.

The panelists also discussed chronic care management systems provided by Phamily and Sweeten Health. Panelist Amy Knighton CPC, FACMPE, SAVANNAH NEUROLOGY SPECIALISTS, P.C., Chief Executive Officer, was working in primary care when she began implementing codes for chronic care management and witnessed significant positive patients outcomes.

“When I came into the neurology space, I saw an immediate application for those codes with our infusing patients,” Knighton said. However, she and her team ran into difficulties when trying to manually scale the process and needed a solution to offset their administrative burden.

“I researched so many companies that offered to help,” she said. “[But] it was outsourcing, it wasn't providing what I wanted our team to be providing. And then Phamily entered the story.”

Knighton explained how as a texting platform for patients, Phamily allows for efficient communication and prioritization of messages using artificial intelligence (AI) technology. Care managers can handle a larger number of patients at a time through the platform and billing is based on the amount of time spent on patient activities within the platform.

Panelist Wendy Van Fossen, CPA, the Neurology Center, chief executive officer, found that Sweeten Health’s system was a better fit for her patients’ needs.

“Our group is a little different in that we have no clinical staff…Sweeten provided staff for me,” Van Fossen said. “Another little secret about our practice is we don’t allow direct patient portal messages, its too much. So our patients can now message [Sweeten].”

Panelist Jeff Greenberg, Craniometrix, Neurologist, Head of Medical Affairs, highlighted the struggle of treating patients with dementia in his private practice while conserving time and earning a profit. “Fortunately, our practice has the grand slam for private practice neurology in the form of the Medicare GUIDE model,” Dr Greenberg said. The model has served his practice well by being scalable, meaningful support for patients with dementia and their caregivers that enhances the brand of his private practice. Panelist Quincy Samus, a professor at Johns Hopkins University and health services researcher who assisted in developing the GUIDE model, shared that GUIDE is an 8 year voluntary testing model. “It really is a culmination of a lot of work that's been done across the nation over the past 15 to 20 years,” she said. “It focuses on testing a comprehensive set of services that are delivered to people who are living with dementia who are Medicare fee-for-service beneficiaries.”

Samus explained that GUIDE is an effort born out of the National Outstanding Project Act (NAFO), which aims to accelerate how treatments are developed and optimizing care in the US. The direct cost of dementia exceeds heart disease and cancer with most of the costs being driven by inpatient hospitalizations, emergency department visits, and premature institutionalization. “If we are successful or at least cost-neutral, this might become something after the 8-year test that we are able to have reimbursed through Medicare,” she said. “And what's also very exciting is that this is the first time that they're actually looking at caregiver outcomes.” Samus also explained that MIND at Home differs from other models in that it is a home-based comprehensive dementia care navigation model. Available to providers via Craniometrix, it directly informed the new CMS GUIDE Model.

Reference 

Knighton A, Van Fossen W, Samus Q, Greenberg J, Patel N. Getting ahead of the game with innovative operations. Presented at: NeuroNet Pro Annual Summit 2025; January 31, 2025; Nashville, TN