Original Research

Effect of a hospitalist–care coordinator team on a nonteaching hospitalist service

Abstract

Abstract

BACKGROUND:

Although many hospitalists work with clinical coordinators, few studies have evaluated their impact.

OBJECTIVE:

The purpose of the study was to evaluate the impact of a hospitalist–care coordinator team on hospitalist work experience, patient satisfaction, and hospital efficiency.

DESIGN AND PARTICIPANTS:

During each of 12 weeks, hospitalists on a nonteaching hospitalist service were randomly assigned to work with a hospitalist care coordinator (HCC) or to work independently.

MEASUREMENTS:

Each week hospitalists completed a survey to assess their satisfaction and perceived work efficiency. Patient satisfaction with hospital discharge was assessed by telephone interviews. Hospital efficiency was analyzed with multivariate linear regression using log‐transformed length of stay (LOS) and cost as dependent variables.

RESULTS:

The 356 patients cared for by hospitalist–HCC teams were similar to 337 patients cared for by control hospitalists. Twenty‐eight of 31 hospitalists (90%) who worked with an HCC responded that the HCC improved their efficiency and job satisfaction. Seventy‐one of 196 eligible patients (36%) completed the postdischarge interview. The mean ratings of overall satisfaction with hospital discharge on a scale of 10 were similarly high in both groups (8.57 vs. 8.37; P = .94). In multivariate regression analyses, LOS was 0.28 days shorter and cost was $585.62 lower for patients cared for by hospitalist–HCC teams; however, these results were not statistically significant (P = .17 and .15, respectively).

CONCLUSIONS:

Hospitalists working in a team approach with an HCC reported improved efficiency and job satisfaction compared with hospitalists working independently. These findings are important in light of growing concerns about hospitalist workload and job satisfaction. Journal of Hospital Medicine 2008;3:103–109. © 2008 Society of Hospital Medicine.

Copyright © 2008 Society of Hospital Medicine

Many hospitalists work with clinical coordinators and case managers.13 The descriptions of these roles often overlap4 and commonly include activities such as obtaining medical records, expediting tests and procedures, coordinating the plan of care with other health care providers, assessing postdischarge needs, completing discharge paperwork, and arranging follow‐up visits.2, 5, 6 Despite the potential to improve patient care and hospital efficiency, few studies have formally evaluated the impact of these roles. Moher et al. found that adding a clinical coordinator to a general medical team decreased length of stay (LOS) and improved patient satisfaction.5 However, this study was conducted at a time when the LOS was routinely longer than it is today. Forster et al. found that adding a clinical coordinator to a general medical team resulted in improved patient satisfaction but did not reduce length of stay or risk of adverse events occurring following hospital discharge.6 Both these studies evaluated the impact of adding a clinical coordinator to resident‐covered medical teams. Yet many hospitalists deliver care without residents, limiting the generalizability of the findings from these studies.

To date, no studies have evaluated the impact of clinical coordinators, case managers, or other nonphysician providers on the hospitalist work experience. This is surprising, as hospital medicine group leaders list daily workload and work hours among their top concerns.7 Clinical coordinators have the potential to improve patient care and hospital efficiency while simultaneously improving the experience of the hospitalists with whom they work. We conducted this study to evaluate the impact of a hospitalistcare coordinator team on hospitalist work experience, patient satisfaction, and hospital efficiency.

METHODS

Setting

The study was conducted on the hospitalist service at Northwestern Memorial Hospital (NMH), a 753‐bed hospital in Chicago, Illinois. The hospitalist service is staffed by 5 hospitalists on duty at a time. Hospitalists work without residents and are on service for 7 consecutive days, usually followed by 7 consecutive days off. Daytime admissions are distributed among all hospitalists on duty in a consecutive fashion. A night float hospitalist performs admissions and all cross‐cover activities from 7:00 PM until 7:00 AM. Nighttime admissions are distributed to day hospitalists based on each hospitalist's daily census.

Study Design

Funding was provided by the hospital for a 12‐week study, and hospital administrative leaders collaborated as part of the research team. During each of the 12 weeks from September 2006 through November 2006, half the hospitalists on duty each week were randomly assigned to work with a hospitalist care coordinator (HCC) in a team approach. Hospitalists not assigned to work with a hospitalist care coordinator continued to work in their usual fashion, which included working with unit‐based care coordinators (UCCs). UCCs follow all patients on a 30‐bed medicine unit but generally do not round with physicians. HCCs performed all the activities that UCCs perform but also performed additional key activities (see Table 1) and worked in a team approach with their hospitalist. Unit‐based social workers and discharge planners were available for all hospitalists during the study. During each day patients were admitted consecutively to one of the hospitalists on service, regardless of their assignment to work with or without an HCC. Similarly, night admissions were distributed to hospitalists without regard to their assignment to work with or without an HCC.

Comparison of Activities Performed by Unit‐Based Care Coordinators (UCCs) with Those Performed by Hospitalist Care Coordinators (HCCs)
Activity typeActivities performed by both UCCs and HCCsAdditional activities performed by HCCs only
Care coordinationDocument the interdisciplinary plan of careEnsure collaboration in formulating the plan of care
Obtain outside medical records
Inform staff nurse of stat orders during rounds
Obtain certain test results (eg, preliminary echo reports)
Patient and family needsAddress patient and family concernsProactively identify and address patient and family concerns
Schedule family meetings
Efficiency of care deliveryRemediate barriers that impede plan of care and/or dischargeIdentify barriers that impede plan of care
Identify and document avoidable daysEnsure tests are scheduled
Discharge processCoordinate discharge plans with social work and discharge plannerSchedule and confirm follow‐up appointments
Initiate discharge instructions
Write discharge prescriptionsverified and signed by physician
Review discharge instructions with patient and/or family

HospitalistCare Coordinator Team

Four HCCs were used in this study. All 4 were registered nurses with specialized training in case management. Prior to the start of the study, the investigators held meetings with hospitalists and the HCCs to describe this new role, the work flow for the hospitalistcare coordinator team, and work activities appropriate for the HCC. Activities related to the discharge process were emphasized as a key feature of the HCC role. Hospitalists and HCCs were instructed to round together as a team each morning. They were advised to collaborate on the daily plan of care and assign specific activities for each to accomplish. During the study weekly meetings were held with the HCCs, the hospitalists with whom they were finishing the week, and the hospitalists with whom they were scheduled to work during the upcoming week. The purpose of these meetings was to ensure that the work flow and work activities were optimal.

Outcome Measures

At the completion of each week, all hospitalists on service were given an anonymous Web‐based survey designed to assess their satisfaction and perceived work efficiency. Hospitalists were asked to rate the efficiency of various work activities during the preceding week on a 5 point Likert scale (1 = very inefficient, 2 = somewhat inefficient, 3 = neutral, 4 = somewhat efficient, 5 = very efficient). Hospitalists who had worked with an HCC were also asked whether they thought working with an HCC improved their efficiency and increased their job satisfaction. We postulated that patient satisfaction with the discharge process might improve with use of the hospitalistHCC team. Therefore, patient satisfaction was assessed by telephone interviews conducted 714 days after discharge. Because of resource limitations, we were only able to interview patient during the second half of the study. Patients were asked to rate their satisfaction with the clarity of verbal and written discharge instructions as well as their overall satisfaction with hospital discharge using a 10‐point Likert scale (from 1 = least satisfied to 10 = most satisfied). Hospital databases provided information on patient demographics, LOS, and cost.

Data Analysis

All analyses were conducted using Stata version 9.0 (StataCorp LP, College Station, TX). Patient characteristics were compared using chi‐square and t tests. Responses to the hospitalist survey for the weeks when they worked independently and the weeks when they worked as a hospitalistHCC team were compared using the Wilcoxon rank sum test. To adjust for the clustering of responses by physicians (ie, individual physicians completed more than 1 survey), we used linear regression and the cluster option. The results were very similar, and only the P values from the Wilcoxon rank sum test are presented. Unadjusted LOS and cost were compared using the Wilcoxon rank sum test. We also conducted multivariate linear regressions using log‐transformed LOS and log‐transformed cost as dependent variables. The independent variable was the team type (whether patients were cared for by a hospitalistHCC team or a hospitalist working independently); age, sex, ethnicity, payer type, and diagnosis‐related group (DRG) weight were included as covariates, and P values were adjusted for physician clustering. We hypothesized a priori that the HCC would have no effect on the LOS of or cost for patients whose hospitalizations were very short. We therefore conducted secondary analyses in which we eliminated patients with an LOS of 1 day or less.

RESULTS

There were 356 patients cared for by hospitalistHCC teams and 337 patients cared for by control hospitalists. Of the 60 weeks of hospitalist service of the study, hospitalistHCC teams accounted for 31 weeks (52%) and control hospitalists for 29 weeks (48%). Patients cared for by the hospitalistHCC teams were similar in age, sex, ethnicity, payer type, and DRG weight to those cared for by control hospitalists (see Table 2).

Characteristics of Patients Cared for by HospitalistHospitalist Care Coordinator (HCC) Teams Compared with Those of Control Hospitalists
HospitalistHCC teamControlP value
n (%) or mean SD
Patients, n (%)356 (51.4%)337 (48.6%)
Age (years)59.3 18.659.0 20.1.86
Women (%)190 (53.4%)192 (57.0%).34
Ethnicity .74
White182 (51.1%)174 (51.6%)
Black111 (31.2%)114 (33.8%)
Hispanic23 (6.5%)21 (6.2%)
Asian5 (1.4%)4 (1.2%)
Other35 (9.8%)24 (7.1%)
Payer .47
Medicare177 (49.7%)168 (49.9%)
Private76 (21.4%)69 (20.5%)
Medicaid43 (12.1%)44 (13.1%)
Capitated43 (12.1%)31 (9.2%)
Other17 (4.8%)25 (7.4%)
Diagnosis‐related group weight1.1 0.81.2 0.8.31

Sixty surveys were completed by hospitalists at the end of their week on service (response rate 100%). Of the 31 responses from hospitalists completing a hospitalistHCC team week, 28 (90%) reported that working with an HCC improved their efficiency and 28 (90%) that working with an HCC improved their job satisfaction. The hospitalists indicated that working with an HCC significantly improved the efficiency of most of their activities (see Table 3). Specifically, activities related to communication with nurses and patients and activities involving discharge planning and execution were improved with the use of an HCC. As would be expected, certain other activities did not improve. For example, there were no differences between the groups in the perceived efficiency of performing histories and physicals or placing admission orders. For activities that were significantly different, the Wilcoxon rank sum test and linear regression analysis adjusting for physician clustering showed identical results.

Differences in Efficiency of Key Work Activities Between Hospitalists with Hospitalist Care Coordinators (HCC) and Control Hospitalists
HospitalistHCC TeamControlP value
Mean score SD*
  • Hospitalists responded using a 5‐point scale (1 = very inefficient, 2 = somewhat inefficient, 3 = neutral, 4 = somewhat efficient, 5 = very efficient).

  • P values for Wilcoxon rank sum tests.

Performing histories and physicals3.94 0.773.93 0.84.98
Performing medication reconciliation3.35 1.082.03 1.18< .001
Placing admission orders3.94 0.734.00 0.87.57
Communicating with nurses4.45 0.683.14 1.09< .001
Communicating with consultants3.65 0.753.34 1.04.25
Communicating with patients4.42 0.623.62 1.01< .001
Communicating with families4.32 0.702.89 1.14< .001
Coordinating discharge plans4.74 0.512.76 1.18< .001
Making/updating sign‐out3.55 0.723.49 0.83.55
Making discharge instructions4.29 0.743.10 1.01< .001
Going over discharge instructions4.48 0.572.76 1.15< .001
Writing discharge prescriptions3.87 0.672.52 1.21< .001
Arranging follow‐up appointments4.19 0.752.03 1.09< .001

Seventy‐one of 196 eligible patients (36%) completed the discharge satisfaction interview. Of the 71 patients interviewed, 44 (62%) were cared for by hospitalistHCC teams and 27 (38%) were cared for by control hospitalists. Patient satisfaction with the clarity of the verbal and written discharge instructions and overall satisfaction with hospital discharge was similar between the 2 groups (see Table 4).

Satisfaction with Hospital Discharge of Patients Cared for by HospitalistHospitalist Care Coordinator (HCC) Teams Compared with That of Patients Cared for by Control Hospitalists
HospitalistHCC Team (n = 44)Control (n = 27)P value
Mean score (SD)*
  • Patients rated items using a 10‐point scale (from 1 = least satisfied to 10 = most satisfied).

Clarity of verbal discharge instructions8.86 ( 2.31)8.44 ( 2.63)0.52
Clarity of written discharge instructions8.95 ( 2.30)8.93 ( 2.54)0.78
Overall satisfaction with hospital discharge8.57 ( 2.42)8.37 ( 2.90)0.94

The unadjusted mean LOS for patients cared for by hospitalistHCC teams was 4.70 4.15 days compared with 5.07 3.99 days for patients cared for by control hospitalists (P = .005; see Table 5). The unadjusted mean cost for patients cared for by hospitalistHCC teams was $10,052.96 $11,708.73 compared with $11,703.19 $20,455.78 for patients cared for by control hospitalists (P = .008). In multivariate analysis using age, sex, ethnicity, payer type, and DRG weight as independent variables and adjusting for physician clustering, LOS remained lower for patients cared for by hospitalistHCC teams; however, this result was not statistically significant (0.28 days, P = .17). Similar multivariate regression analysis showed a trend toward lower cost for patients cared for by the hospitalistHCC teams (585.62, P = .15).

Differences in Length of Stay and Cost between Patients Cared for by HospitalistHospitalist Care Coordinator (HCC) Teams and Patients Cared for by Control Hospitalists
Unadjusted mean (SD)P value for unadjusted difference*Adjusted difference with hospitalistHCC teamP value for adjusted difference
  • P values for Wilcoxon rank sum tests.

  • P values for multivariate analyses with adjustment for age, sex, ethnicity, payer type, diagnosis‐related group (DRG) weight, and physician clustering.

Length of stay
HospitalistHCC teams4.70 (4.15).0050.28.17
Control hospitalists5.07 (3.99)
Cost
HospitalistHCC teams10,052.96 (11,708.73).008585.62.15
Control hospitalists11,703.19 (20,455.78)

DISCUSSION

Our study found that hospitalists working in a team approach with an HCC rated the efficiency of their daily work and their job satisfaction significantly higher than did control hospitalists. Specific areas of improved efficiency included communication activities and activities related to hospital discharge. A prior study conducted by our group found that hospitalists spend a lot of time on indirect patient care activities such as communication and activities related to the discharge process, while spending relatively little time on direct patient care.8 Improving the efficiency of indirect patient care activities of hospitalists is likely to improve their job satisfaction. The importance of improving hospitalist workload and job satisfaction is underscored by the relatively high number of hospitalists at risk for burnout9 and the growing concern about daily workload among hospital medicine group leaders.7

Patient satisfaction was not significantly affected by the use of the hospitalistHCC team in our study. A priori, we postulated that patient satisfaction with the discharge process might improve with the use of the hospitalistHCC team. We therefore limited survey questions to assessing only satisfaction with hospital discharge rather than other aspects of patient hospital care. A recent study reported that patients rated the quality of discharge instructions significantly lower than they rated the overall quality of their hospital stay.10 However, the patients in our study gave high ratings to both discharge instructions and overall satisfaction with hospital discharge. This may explain why we were unable to detect a difference. Our study was limited by the relatively small number of patients we were able to contact to assess satisfaction. Previous studies evaluating the impact of care coordinators either did not assess patient satisfaction with discharge5 or found no difference in satisfaction with hospital discharge.6

Although our study did not find a difference in patient satisfaction with the discharge process, we believe the hospitalistHCC model has the potential to complement efforts to reduce the risk of adverse events as patients transition out of the hospital. It has been reported that 12% of patients have a preventable or ameliorable adverse event in the period immediately following hospital discharge.11, 12 Although Forster et al. did not find a reduction in the risk of adverse events with the addition of a clinical coordinator to a general medical team, they noted incongruence between the coordinator's role and the outcomes measured.6 Similarly, we would need to modify the role of the HCC from a position designed mainly to improve efficiency to one that complements efforts to improve the quality of the discharge process. Possible ways to enhance the HCC role in this regard include increasing the emphasis on and training in patient education skills. Several recently published articles have emphasized the need to redesign the discharge process in an effort to reduce the risk of adverse events following hospital discharge.1315 A modified HCC role might be an essential feature of a redesigned multidisciplinary discharge process.

We were unable to demonstrate improved efficiency for the hospital. Although LOS and cost were lower for patients cared for by the hospitalistHCC teams, the difference was not statistically significant. One possible explanation for why we did not observe a larger reduction in LOS is that our hospitalist service had a lower‐than‐average patient volume during the study period. The lower volume mirrored an unanticipated dip in hospital volume during the same period. Specifically, our service normally discharges an average of 338 patients per month, but during the study period we discharged an average of 235 patients per month. A potential LOS and cost benefit may have been attenuated by the relatively low volume, as hospitalists had ample time to dedicate to communication and coordination of discharge plans.

Our study had several limitations. It was conducted on a nonteaching hospitalist service at a single site. Hospitalist practices vary widely in their staffing and scheduling models. As previously mentioned, we were only able to perform patient satisfaction surveys during the second half of the study period. In addition, hospitalistHCC team patients made up a larger percentage of the patient survey responses (62%) than did control hospitalist patients (38%). This may have affected our ability to detect differences in satisfaction with the hospital discharge process. As also previously noted, our patient volume was lower than normal during the study period. We believe that a higher volume would have magnified differences in hospitalists' perceived efficiency and perhaps resulted in significant improvements in LOS and cost. Finally, the hospital provided funding for only a 12‐week study. This limited our sample size and the power of the study to detect important differences. It is possible that a larger sample size and/or longer study period may have been able to demonstrate a statistically significant improvement in LOS and cost.

Our findings are of particular importance in light of the persistent concerns about hospitalist workload and job satisfaction. Although many hospitalists work with clinical coordinators and case managers, we believe that having the formal structure of a hospitalistcare coordinator team was the key element to improving hospitalist efficiency and satisfaction. We hope that our study is a precursor to research evaluating models of delivering hospital care and their impact on hospitalist work experience, hospital efficiency, and patient outcomes.

References

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