Lee A. Lindquist, MD

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

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).

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.

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).

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).

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.

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

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).

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.

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).

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).

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.

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

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).

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.

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).

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).

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.