Neuro Telehealth and Transitions of Care Program

The Neuro Telehealth Care and Transitions of Care Program at Our Neuro Network provides longitudinal, specialty-led clinical oversight for adults affected by acute, chronic, and complex neurological and neurovascular conditions.

This program is intentionally designed to address the most fragile points in neurological care: transitions between settings, when patients are most vulnerable to fragmentation, missed diagnoses, preventable deterioration, emergency department utilization, and hospital readmission.

Care is delivered primarily via telehealth, with availability for facility-based consultation and rounding when clinically appropriate.

Why Our Program Exists

Neurological illness does not pause at discharge or after specialty appointments. Neurological care often extends beyond a single hospitalization or specialty visit. As patients transition between care settings, new questions can emerge, symptoms may evolve, and follow-up needs can become complex. Families are frequently asked to coordinate care across settings without a consistent source of longitudinal neurological oversight. This program exists to change that.

This work is deeply personal.

I am both a neuroscience clinician and a patient with an inherited neurometabolic syndrome. My mother shared this condition. In the weeks before her death, she sought emergency care multiple times for neurological symptoms. Her presentation was repeatedly misunderstood and attributed to developmental delay and low intelligence, characterizations that could not have been further from the truth.

She did not receive the neurological care she needed. Her symptoms reflected a treatable condition, yet without longitudinal neurological synthesis across encounters and care settings, critical patterns were missed. She fell through the cracks of a fragmented system. Her death was preventable.

The system of care being built at Our Neuro Network is the system I wish had existed for my mother, and for families like my own. It exists to support patients navigating acute illness, recovery, and long-term neurological care with continuity, advocacy, and respect for the full complexity of their lives.

Who We Serve

We provide specialty care for adults with:

• Acute neurological events including stroke, neurovascular syndromes, seizures, encephalopathy, and neurocritical illness

• Chronic and progressive neurological conditions

• Complex neurovascular, neurometabolic, and multisystem neurological disorders, including cerebral venous and cerebrospinal fluid (CSF) disorders, intracranial hypertension, intracranial hypotension, headache, migraine, cognitive dysfunction, and dementia

• High-risk patients vulnerable to readmission, ED utilization, or functional decline during care transitions

Program Focus

This program supports patients across:

• Acute care hospitalization

• Skilled nursing facilities (SNFs)

• Long-term acute care hospitals (LTACs)

• Assisted living and memory care centers

• Home-based recovery

The defining feature of this model is continuity of neurological oversight, even as care settings change.

Scope of Clinical Services

Services may include:

• Neuroscience and neurovascular consultation

• Transitional and post-acute rounding

• Longitudinal neurological care management

• Review and synthesis of complex medical histories, imaging, and diagnostics

• Early identification of neurological decline or evolving syndromes

• Coordination with interdisciplinary teams

• Support for patients and families navigating complex decisions

• Strategies to reduce avoidable emergency department visits and hospital readmissions

All services are individualized and guided by clinical judgment, current evidence, and patient-specific needs.

Care Philosophy

Neurological disease rarely conforms to a single visit or isolated episode of care. Effective management requires time, pattern recognition, continuity, and synthesis across settings.

This program functions as a specialty adjunct, not a replacement for primary care or subspecialty neurology. Whenever possible, Our Neuro Network collaborates with neurologists, neurosurgeons, primary care clinicians, rehabilitation teams, and facility staff to support safe transitions and optimal outcomes.

Clinical recommendations are guided by patient need rather than volume, speed, or administrative pressure.

Telehealth and Location

Telehealth services are available to patients physically located in Hawaii and Arizona at the time of service, subject to payer participation and regulatory requirements.

Prescribing and Regulatory Considerations

Prescribing of medications via telehealth is governed by federal and state law. Controlled substances are prescribed only when legally permissible and clinically appropriate. Non-controlled medications may be prescribed when indicated. Scope may evolve as regulations change.

Emergency Disclaimer

Telehealth services are not appropriate for medical emergencies. Patients experiencing urgent or emergent symptoms should call 911 or present to the nearest emergency department.

Post-Acute and Facility-Based Specialty Care

SNF, Assisted Living, Memory Care, and LTAC Services

Our Neuro Network provides neuroscience and neurovascular specialty consultation, rounding, and care management for post-acute and long-term care settings.

This service is designed to support facilities caring for patients with complex neurological needs while reducing avoidable transfers, emergency department utilization, and readmissions.

Facility-Based Services May Include

• Specialty neurological consultation for complex patients

• On-site or hybrid rounding when clinically appropriate

• Longitudinal oversight during rehabilitation and recovery

• Identification of evolving neurological syndromes

• Support for staff and families navigating neurological decline

• Coordination with hospital teams during admissions and discharges

• Discharge planning and safe transition support

Availability is based on clinical appropriateness, facility agreements, and capacity.

Secure Messaging

Secure messaging via Spruce is available to established patients for clarification of recommendations, updates, and limited care coordination. Messaging is not urgent or emergent and is reviewed during regular business hours.

Capacity and Availability

To maintain safe, attentive, and thoughtful care, appointment availability may be limited. New patient scheduling may pause when clinical capacity is reached.

Licensure and Expansion

Clinical services are provided only in states where appropriate licensure is held. Non-clinical coaching and consulting services are offered separately under distinct agreements.