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Enter the Neurohospitalists The solution to a problem

Enter the Neurohospitalists The solution to a problem. David Likosky MD SFHM Hospitalist Neurology/Internal Medicine Vascular Neurology Evergreen Hospital . A brief Hospitalist Hx Definition What problem are we trying to solve? Who are these people?

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Enter the Neurohospitalists The solution to a problem

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  1. Enter the NeurohospitalistsThe solution to a problem David Likosky MD SFHM Hospitalist Neurology/Internal Medicine Vascular Neurology Evergreen Hospital

  2. A brief Hospitalist Hx • Definition • What problem are we trying to solve? • Who are these people? • What are the advantages and disadvantages?

  3. Hospitalists Response to failings of inpatient general medical care

  4. Hospitalists 80% of hospitals >200 beds 3,300 hospitals nationally 30,000 hospitalists total SHM 2011

  5. The evolution of the model Filling the call schedule Not losing too much money Looking at outcomes Documenting value

  6. Neurohospitalists A physician whose primary professional focus is the neurological care of hospitalized patients. adapted from Nelson J, SHM

  7. Why Neurohospitalists? • Two places • Hospital Practice • SHM survey • Workforce issues

  8. It is difficult to be in two places at once

  9. Examples • The busy office, a tPApt arrives • Covering two hospitals on call • Trade overhead/paying patient for liability/no pay

  10. Multitasking • Hospitalists - 3.4 times/hour • ER docs • q5 minutes • 2/3 did not return to prior task O’Leary, KJ, et al, J Hosp Med, 2006, Chisolmet. al. AcadEmerg Med. 2000

  11. How has the hospital changed? Wachter, NEJM 2004, Freeman Neurol. 2008, Josephson Annal Neurol. 2008

  12. How has the hospital changed? Wachter, NEJM 2004, Freeman Neurol. 2008, Josephson Annal Neurol. 2008

  13. How has the hospital changed? Wachter, NEJM 2004, Freeman Neurol. 2008, Josephson Annal Neurol. 2008

  14. How has the hospital changed? Wachter, NEJM 2004, Freeman Neurol. 2008, Josephson Annal Neurol. 2008

  15. How has the hospital changed? Wachter, NEJM 2004, Freeman Neurol. 2008, Josephson Annal Neurol. 2008

  16. How has the hospital changed? Wachter, NEJM 2004, Freeman Neurol. 2008, Josephson Annal Neurol. 2008

  17. How has the hospital changed? Wachter, NEJM 2004, Freeman Neurol. 2008, Josephson Annal Neurol. 2008

  18. How has the hospital changed?

  19. How has the hospital changed?

  20. How has the hospital changed?

  21. Are we doing a good job in the hospital now?

  22. Survey of Internal Medicine Hospitalists

  23. Have you had difficulty getting full stroke call coverage? Likosky et al, 2008

  24. Is it difficult to get a neurologist to see a stroke patient? Likosky et al, 2008

  25. Portion of stroke patients seen by a neurologist? Likosky et al, 2008

  26. Who did the stroke care nationally? Neurologist Other Smith et al, Cerebrovasc Dis 2006

  27. Is there a clinical difference if Neurologists are involved?

  28. All that aside... Are there enough Neurologists to see all the patients?

  29. AAN US Membership 25,000 20,000 15,000 10,000 5000 1950 1960 1970 1980 1990 2000 2004 2008 196 PGY-1 & 385 PGY-2 Neurology Positions in 2009 NRMP 2009, AAN census 2009

  30. Hospitalists 15,000 projected 4,922 PGY-1 categorical Internal Medicine Positions in 2009 SHM website, 2009; NRMP 2009

  31. Advantages of Neurohospitalistsfor other Neurologists • Less (or no) inpatient call • Uninterrupted clinic • Increased income? • Less stress

  32. Advantages of Neurohospitalistsfor Patients • Timely care • Better outcomes - if internal medicine data holds • Decreased length of stay? • Increased physician availability • Alignment of interests

  33. Advantages of Neurohospitalistsfor Hospitals • Medical staff satisfaction • Hospitalist qol • Call coverage • Stroke center certification? • Alignment of interests • ? Decreased liability

  34. New hospitalist programs • Thank you for answering my call

  35. Advantages of Neurohospitalistsfor Neurohospitalists • Qol - possibly • Less risk? • More defined hours/responsibilities

  36. Neurohospitalist Disadvantages • Discontinuity of care • Costs of a neurohospitalist • Changes in skillset over time? • Privileging/credentialing changes? • Competition with outpatient practices?

  37. Who are the neurohospitalists? • Average age 42 • 82% male • Split between academic and private • 73% primarily inpatient focused (US neurologist 53, hospitalist 40) (US neurologist 76%, hospitalist 62%) AAN survey 2009 SHM survey 2007-8 Likosky et al, 2009

  38. Clinical work - what do neurohospitalists see? • Stroke • Encephalopathy • Seizure • Neuromuscular • CNS infection

  39. Non-clinical work • 18% of time • 42% receive additional compensation Likosky et al, 2009

  40. How are IM Hospitalists paid? “Call” isn’t Society of Hospital Medicine, 2010

  41. Neurohospitalist Salaries Pay for call? Likosky et al, 2008

  42. Pay for non-clinical work Likosky et al, 2008

  43. What beyond direct patient care? • Pathways • CPOE • Education • Telemedicine • Delirium prevention • Hospital administration • Outcomes driven care • Role in ACO’s • Joint Commission mandates/stroke centers

  44. Conclusion • Site specific specialists now in many fields • Well positioned for changes in healthcare • Strong alternative to traditional practice • Likely to continue growing rapidly likosky@gmail.com

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