Factors to Consider in Developing a Neurohospitalist Program

Hospitals are turning to neurohospitalists as a cost-effective means to improve coverage and care.

The Demand for Neurohospitalists

With fewer neurologists willing to cover inpatient consultations and provide Emergency Department-call coverage, hospitals have found that they can achieve stability by starting or expanding neurohospitalist programs.

Neurohospitalists provide inpatient care, take “stroke-call”, administer tPA and help to meet overall neurology demands. Focusing on inpatients with, or at risk for, neurologic disease, they have often helped reduce readmission rates by coordinating effective outpatient treatment.

Surging membership in the Neurohospitalist Section of the American Academy of Neurology (AAN) is reflective the demand. Formed in 2009, the section already had almost 600 members as of early 2013—after rising 20 percent within the preceding year alone.

3 Neurohospitalist Hiring Factors

The hiring outlook also is positive. Of 63 leaders of accredited U.S. adult neurology training programs surveyed, 24 reported that their institution already employed neurohospitalists and 10 more departments planned to hire neurohospitalists within the next year, which would bring the total to more than half of the academic neurology departments that participated in the survey, according to results published in The Neurohospitalist in January 2014.

Here are three factors to consider when starting or expanding a neurohospitalist program.

1) Patient Care – Neurohospitalist support improves care by providing specialized inpatient neurological expertise as well as general neurological assistance to all hospital departments, including the ED and the intensive care unit, according to the Strategic Plan for the AAN’s Neurhospitalist Section. Neurohospitalists also promote best practices.

When hiring a neurohospitalist, consider their ability to work across departments and with other specialists—internally and externally—to coordinate care and improve outcomes.

2) Education – As “site-specific” specialists, neurohospitalists are more accessible to and involved with medical students than part-time attendings, according to the AAN. Such directed learning can help better prepare students for practice.

So, consider a potential neurohospitalist’s effectiveness as a trainer of students and residents.

3) Medical economics –  The AAN has found that neurohospitalist programs typically fall into one one of the following models: academic based; salaried or productivity-based by hospital administrators; salaried or productivity-based by multi-specialty groups; productivity based by single neurological specialty groups; or base salaried plus productivity based by single specialty neurohospitalist groups.

Neurohospitalist Practice Models

But hospital physicians, staff and administrators stretch their access to scarce neurology resources, and 20 percent or more of the patients that neurohospitalists treat are indigent, uninsured or non-payers, according to the AAN.

Thus, the AAN recommends that neurohospital practice models account for: predominantly cognitive work; hospital inefficiencies; inadequacies in relative value units (RVUs); Physician Quality Reporting System (PQRS) strategies; procedures such as carotid duplex interpretation and lumbar spinal procedures; nonpaying populations and call requirements.

Perhaps above all, when hiring a neurohospitalist, consider that their concerns differ from neurologists in other practice settings.

For example, neurohospitalists focus on process improvement (like as measured in outcomes and patient flow), medical education, and integrating into the greater hospital system. These concerns transcend non-academic and academic environments, as departments struggle to balance resources while providing increasingly complex care in health systems that value the tracking of quality and safety measures, according to the AAN.

Though some hospitals—particularly smaller ones—may perceive neurohospitalist programs as prohibitively expensive, their benefits can justify the investment, particularly when reimbursements are tied to quality and safety measures, such as in the Hospital Value Based Purchasing Program (VBP) being implemented by the Centers for Medicare and Medicaid Services (CMS).

San Francisco Medical Center Neurohospitalist Program

The neurohospitalist group at the University of California, San Francisco Medical Center halved the 30-day readmission rate for neurology patients, bringing it to about 10 percent, through a systematic and multidisciplinary review of each readmission as well as individual interventions, according to a May 2014 article in Hospitals & Health Networks.

Reflecting how neurohospitalists can add value for a hospital by focusing on best practices in patient care, UCSF’s group established post-discharge protocols to address common contributors to readmissions, including patients’ straying from their medication and care plans, rapidly deteriorating conditions and lengthy waits for follow-up visits with outpatient neurologists, according to Hospitals & Health Networks.  A neurohospitalist  provides continuity of care by following up on planned tests and prescribed medications as well assessing the patient’s health status.

The development of practice models that smoothly and safely transition between inpatient and outpatient neurological care is critical to the long-term sustainability of neurohospitalist programs, according to the AAN.

So, too is the continued development of a skill set unique to the practice of inpatient neurology, which hospitals should look for in potential neurohospitalists as more physicians begin to practice this neurological subspecialty to meet the increasing demand for their services.

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