Reimagining Neurologic Care Through Population Health Strategies

More than 180 million Americans—over half the population—are living with a neurologic disease or disorder, according to the American Academy of Neurology. Traditional specialty care is fragmented, reactive, and unable to meet the challenges of an aging population and rising demand for care access.

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Two Mass General Brigham Neuroscience Institute neurologists—Lidia M.V.R. Moura, MD, MPH, PhD, and Merit E. Cudkowicz, MD, MSC—are exploring how population health approaches could help set a better path forward. They are among the authors of a paper published in Neurology Clinical Practice that shares relevant case studies and lessons learned from five prominent academic health systems.

Seeking out other leaders in population health

Upon being named population health director for the Massachusetts General Hospital Department of Neurology in 2024, Dr. Moura was charged with doing what she calls an “environmental scan.” What did population health mean at Mass General Brigham? And how could population health support the system’s core pillars of patient care, research, teaching, and community health?

Dr. Moura sought to speak with leaders in population health at Mass General Brigham and other health systems. Dr. Cudkowicz joined her in the effort and cited the timeliness of the work given the challenges and opportunities facing the neuroscience field.

“We’re seeing a lot of breakthroughs in understanding brain, spinal cord, and neuromuscular disorders, with many new treatments coming on the market or in trials,” Dr. Cudkowicz says. “But we also have huge access problems that aren’t solvable by simply hiring more neurologists, neurosurgeons, or psychiatrists. That inspired us to ask, ‘How can we make sure people can access these great breakthroughs?’”

The research team cast a wide net, reviewing all U.S. academic health systems with published or publicly reported integrated neurology initiatives between 2014 and 2024. Ultimately, they chose case studies from five institutions with diverse organizational structures, reimbursement models, and geographic representation: Mass General Brigham, Cleveland Clinic, Mayo Clinic, Vanderbilt University Medical Center, and Kaiser Permanente.

“We spent almost a year learning from these institutions,” Dr. Moura says. “Instead of just creating a technical report for our leadership, we decided to make it public. We also decided to share the challenges and possibilities with a larger audience because we want not only to improve care within the population that we serve but also to have a broader national and international reach.”

Highlighting innovations at the Neuroscience Institute

For the Mass General Brigham case study, the authors of the Neurology Clinical Practice paper reviewed three key initiatives underway at the Neuroscience Institute.

Structured dementia care pathways

With neurologic diseases and disorders, Dr. Moura says, “We need to identify people earlier in the disease course. That allows us to provide them with better access to care and better treatment options, including clinical trials, so that we can improve their outcomes.”

And yet, Dr. Moura adds, studies have shown that with dementia, mild cognitive impairment screening typically doesn’t start until three to five years after onset of clinical symptoms. Accordingly, Mass General Brigham is taking steps to ensure people at high risk are seen by a neurologist before memory loss begins or progresses significantly.

Dr. Moura and her colleagues have developed an agentic artificial intelligence workflow that scans massive amounts of clinical notes from patients’ electronic health records to detect very early signs of cognitive impairment. The system can pick up even subtle signals that may be overlooked or ignored in real time, such as a missed medical appointment or medication nonadherence.

“It could be a detail found in an intake form or in a discharge note from an ophthalmology visit,” Dr. Moura says. “We can then flag that patient as someone who may benefit from a formal cognitive evaluation.”

Digital evolution

More and more, people are turning to patient portals to communicate with their physicians. According to Dr. Moura, some departments at Mass General Brigham have seen an over 500% increase in message volume in recent years. “That has outgrown our human ability to handle and screen all those messages in real time,” she says.

The Neuroscience Institute has partnered with Digital Patient Experience at Mass General Brigham to tackle this challenge. One of their most impactful interventions has entailed using AI to review portal messages, route them to the appropriate parties, and draft compassionate replies (which are vetted by humans before being sent to patients).

Dr. Moura reports that redesigning the in-basket workflow substantially accelerated the initial response to patient messages without increasing headcount. Median time to first action fell from 11.3 to 1.0 hours at one division and from 16.1 to 0.6 hours at another. Controlled analysis demonstrated a significant 92.5% immediate reduction in time to first action at the first division, reflecting improved responsiveness—an important dimension of access to care in the patient portal environment.

“In neurology, the future isn’t about just adding more people. It’s about building systems that allow us to care for more patients with the workforce we already have,” Dr. Moura says. “Improving efficiency frees us up to do what we signed up for: caring for patients to the best of our abilities.”

Multidisciplinary headache care

Patients with headache disorders, including migraine, often encounter long wait times for appointments. This can lead them to go to the emergency room for care that could have been delivered in the outpatient setting—not an ideal outcome.

One of the Neuroscience Institute’s top priorities for 2026–2028 is to boost access for headache care, which represents the majority of primary care referrals to neurology, Dr. Moura says. The formation of a virtual integrated practice unit (IPU) for headache care is the centerpiece of this plan.

The IPU brings together neurology, advanced practice providers, primary care, emergency medicine, radiology, pharmacy, informatics, researchers, and patient advocates from across Mass General Brigham’s academic medical centers and community hospitals. Members regularly convene in virtual huddles, sharing challenges, lessons learned, and ideas for centering care around patient needs.

The entire IPU team is mindful that while some patients should be cared for by a primary care provider, others might be better served by a general neurologist, headache specialist, clinical social worker, pharmacist, or other clinician. The goal, Dr. Moura says, is “to have the right provider caring for each patient in a timely manner.”

The IPU will also provide a real-world setting for a newly funded, three-year study led by Dr. Moura to develop, validate, and implement digital migraine quality measures. Building on established headache quality standards, the study will examine how clinical data can be used to identify gaps in preventive migraine care and support improvement across primary care and neurology.

Members of the IPU share a real-time dashboard tracking emergency department-to-neurology and primary care-to-neurology intervals, clinical performance measures, and patient-reported outcomes. Plans call for additional digital tools that can help care teams identify patients who may benefit from preventive treatment or other interventions.

“We’re looking to develop digital metrics that help us identify which patients may not be receiving care that meets our quality standards,” Dr. Moura says. “We also want to identify vulnerable patients and populations so we can improve access and quality of care in a scalable way.”

Key takeaways from other organizations

Dr. Moura, Dr. Cudkowicz, and their co-authors also reviewed case studies from four other centers that are adopting population health frameworks that coordinate services across specialties and settings. Here are their key takeaways from each.

Cleveland Clinic

Cleveland Clinic has operated mobile stroke units—specially equipped and staffed ambulances that expedite stroke diagnosis and thrombolytic treatment before hospital arrival—since 2014. A prospective, multicenter trial confirmed significantly shorter onset-to-treatment times and better 90-day functional outcomes, as measured by disability scores.

“We learned a lot about their mobile stroke units, which show that care can be moved closer to patients, improving outcomes and satisfaction,” Dr. Moura says.

Mayo Clinic

Mayo Clinic has a nationwide referral network with a teams-based infrastructure and salary-based model. Its “integrated community specialist” approach embeds neurologists in primary care clinics, reducing tertiary referrals by 64%, in-person visits by 25%, and unnecessary testing by 22%, according to one study.

“Mayo has managed to preserve specialist capacity for complex cases, which is an extremely important lesson learned as we redesign access workflows at Mass General Brigham and look to embed neurologists into our primary care workflows,” Dr. Moura notes.

“With these integrated population health models that embed neurologists within primary care practices, you’re not only helping to get patients the right care at the right time,” Dr. Cudkowicz adds. “You’re also educating and providing tools to primary care doctors, who are often the first to see people with memory disorders, tremors, or Parkinson’s disease.”

Vanderbilt University Medical Center

Vanderbilt University Medical Center extends its neurology expertise to its sizable rural population via a teleneurology network that delivers virtual consultations for acute stroke, seizures, neuromuscular emergencies, and follow-ups across 12 community hospitals. Surveys showed 96% of physicians and 89% of patients felt their needs were met.

“Vanderbilt’s success in implementing and sustaining effective, low-cost telehealth solutions is remarkable,” Dr. Moura says.

Kaiser Permanente

Kaiser Permanente has an integrated payer-provider model that aligns incentives with long-term outcomes in the management of chronic neurologic diseases. Through its Multiple Sclerosis Treatment Optimization Program, the organization defined standardized protocols that cut $161.6 million in therapy costs.

“From Kaiser, we can learn how certain programs can be implemented more readily,” Dr. Moura observes. “And because of the way the organization is structured, we can see how costs can fall while quality improves in a more aligned and streamlined fashion.”

Moving forward in the face of obstacles

From program implementation and sustainability to the substantial upfront investments required for infrastructure and workforce realignment, Drs. Moura and Cudkowicz acknowledge that many obstacles stand between the current state of neurologic care and the brighter future they envision. They contend that adopting population health approaches could help make their dream a reality.

“It’s a challenging financial time for innovation in health systems, but that shouldn’t stop us from moving forward,” Dr. Moura concludes. “Through hub-and-spoke collaborations, shared governance, the creation of structured care pathways, the integration of AI, and other thoughtful strategies, we can improve access, quality, efficiency, and outcomes in neurologic care—all without the luxury of a transformational budget.”

Learn about the Neuroscience Institute

Learn about the Center for Value-Based Health Care and Sciences