NATIONAL HARBOR, MD. — Hospitalists within a practice most likely know which of their colleagues want time off on nights and weekends, but they probably haven't given a lot of thought to how to efficiently assign new patients, Dr. John Nelson said.

Managing patient assignments successfully improves physician and patient satisfaction, said Dr. Nelson of Nelson Flores Hospital Medicine Consultants, La Quinta, Calif., and Dr. Troy W. Ahlstrom, chief financial officer of Hospitalists of Northern Michigan, Traverse City.

A successful assignment system feels fair to the hospitalist, supports continuity of care, and allows other physicians in the hospital to always know which hospitalist is caring for a patient, said Dr. Nelson, who also is the medical director for the hospitalist practice at Overlake Hospital, Bellevue, Wash.

One commonly used method involves distributing patients sequentially and assigning based on location—for instance, one physician takes floors 1 and 3, and another floors 2 and 4. Load leveling also is common, but can be time consuming to manage, Dr. Nelson said. With that method, the next patient is assigned to the physician with the lightest patient load at that time.

Less common is uneven assignment, when one physician might take all the admissions on one day and none the next. Another method is for a hospitalist to be paired with a primary care physician, taking all of his or her patients. With this approach, the primary care physician will always know who is covering his or her patients, and patients who are admitted repeatedly will always have the same hospitalist. A variation is for repeat patients to always be admitted by the same physician.

Even with an assignment scheme in place, hospitalists have to be prepared to cope with special cases, such as “bounce backs”—patients readmitted shortly after discharge. Dr. Nelson suggested establishing a formal policy on how to handle such situations. Formal policies should also be in place for assignment exceptions when one hospitalist is at the cap for new admissions and the others in the practice are not, or when other physicians request a consultation with a specific hospitalist. Finally, practices should anticipate what to do when a patient “fires” a particular hospitalist, and they should have a policy for that, he said.

Using a “triage” or “hot” pager, in which all patients are routed first through the pager operator, usually a hospitalist, can also help with assignments, Dr. Nelson said.

Another option is exempting hospitalists from taking any new admissions the day before they rotate off shift. Assuming that the average length of stay is 4 days and that hospitalists work 7 consecutive days, this method of assignment means that 71% of patients will see the same physician throughout their stay, Dr. Nelson said. If, instead, the physician gets the same patient load every day, including the day before going off shift, only 57% of patients will see the same hospitalist for the duration of their stay.

The advantages of the exemption scheme include better continuity of care, fewer handoffs, and more time for the physician to “tee up” patients for the incoming hospitalist, Dr. Nelson said. However, it also means that the other physicians in the practice will need to take more patients on some days.

Dr. Ahlstrom said the traditional model of 7 days on/7 days off did not work well at his practice at the Alpena (Mich.) Regional Medical Center. So the Alpena practice instituted a flexible full-time equivalent (FTE)–based work schedule that allows each hospitalist to tailor his or her patient load each day.

It's a somewhat complicated approach, however. The FTE is defined by the number of patients seen per day—for instance, if the FTE is defined as 16 patients a day, and the practice admits about 160 patients daily, 10 FTE physicians are needed to cover each day. Physicians are queried about how many patients they want to take on each day. They are assigned FTE numbers based on patient load and then scheduled accordingly so that the entire practice has coverage for all of the anticipated admissions.

The flexible schedule lets the physician work in a pattern that is optimal for his or her lifestyle and compensation needs, Dr. Ahlstrom said. Finally, although it's a great retention tool because it allows physicians to maintain a work-life balance, it can make recruitment more difficult because there can be some initial resistance to nontraditional scheduling, he added.

Compensation is based solely on productivity, which may give some hospitalists pause. Because it is so complicated, the Alpena practice has a dedicated employee who works 20–40 hours a week solely on scheduling at the three hospitals it serves. Start-up costs are about $20,000, primarily for the software and hardware needed, he said.

Disclosures: Dr. Ahlstrom disclosed that he is a consultant with Hospital Solutions of Michigan. Dr. Nelson reported that in addition to his consultancy, he is a stockholder in Ingenious Med.

Managing Patient Assignments Properly Boosts Efficiency