By Ron Southwick
May 2, 2024
Source: VOX
Photo Source: Unsplash,
Hospital leaders are growing more frustrated by the number of patients they are housing because they can’t send patients to nursing homes or other post-acute facilities.
Health systems and hospitals have been dealing with delays in discharging patients for years, but the problem appears to be worsening.
Hospital leaders have routinely bemoaned the fact that they are housing patients who no longer need to be in a hospital setting, but aren’t healthy able to go home. But they say they are stuck caring for many patients because there aren’t beds available in nursing homes, rehabilitation centers or other post-acute facilities.
Patients are regularly staying in hospitals for days and weeks because they can’t be discharged.
While it’s less common, hospital leaders say some patients have been housed for months because of the inability to send a patient to a post-acute setting. Two statewide hospital leaders say some patients have stayed in hospital beds for more than a year.
Cassie Sauer, president and CEO of the Washington State Hospital Association, says the long patient stays for those who don’t need acute care are adding to the financial strain of hospitals.
“They're lasting days, they are lasting weeks, they are lasting months, and occasionally they're lasting years,” Sauer said. “There's a lot, many more patients, in the days category.
But that really adds up if you've got a ton of patients that stay for three extra days.”
The discharge delays are adding to the financial challenges for many hospitals, officials say.
Since hospitals aren’t providing acute care to those patients, they don’t get the same level of reimbursements. Hospital officials also say those patients are taking up beds that could go to other patients who need acute care (and would bring better reimbursements).
If patients are getting acute care that’s covered by an insurance claim, Sauer said, “You don’t get paid. You’re not getting paid for it.”
The American Hospital Association and other advocates have pushed the government for reimbursement for housing patients that no longer need acute care. While lawmakers have expressed interest, there’s no sign that such aid is coming.
Staying longer
The California Hospital Association says that on any given day, 4,500 patients are staying in California hospitals longer than necessary due to delayed discharges. Carmela Coyle, president and CEO of the California Hospital Association, said over the course of a year, patients are spending 1 million days unnecessarily in California hospitals, even though they are ready for discharge.
“We have patients who are staying longer in the inpatient hospital setting than is appropriate, or that is necessary,” Coyle said. ”That means that those patients are backing up in the emergency departments, who are waiting for that bed otherwise available in the hospital. And most important, it means that patients are unable to get the level of care that they need.”
The California Hospital Association filed suit last week against Anthem Blue Cross, one of the state’s largest insurers. The association says the insurer is essentially forcing hospitals to keep patients longer than necessary.
“We are hopeful that the action that the court may take will influence the actions of other insurance companies and ultimately put an end to these harmful practices,” Coyle said in a news conference last week.
Sean Maiorano, MD, chief medical officer of Enloe Health, a 298-bed hospital in Chico, California, says delays in discharges of patients can run days or weeks.
“It's not uncommon for people to be here seven to 10 days beyond what they need to be before they get discharged,” Maiorano said. “As I illustrated, there's also extreme cases which, over the course of my career, I've seen it become more common where people are here for months.”
Maiorano says a long delay “creates obviously a big, big stress for the patient, as well as our case management team to try and do that work to try and get those patients to the right level of care.”
Maiorano relayed a story involving a patient from another country who was visiting California. After he no longer needed acute care, hospital staff tried unsuccessfully to get him placed in dozens of post-acute facilities. His family ultimately flew him back to his home country.
Vicki White, chief nursing officer of Henry Mayo Newhall Hospital in Santa Clarita, California talked about the growing problem of delayed discharges during the California Hospital Association’s announcement of its lawsuit.
“On average, what we're seeing in a good smooth authorization process is three to five days,” White says of delays. “But it can take up to two weeks.”
Hospitals have also pushed back against the federal government’s plan for minimum nurse staffing standards in nursing homes, largely because they fear that nursing homes will close even more beds to meet the standards. While advocates for seniors say the standards could improve care in nursing homes, hospitals say they fear that it will become even harder to discharge patients who no longer need acute care.
‘There’s a toll’
In Wisconsin, hundreds of people are regularly occupying beds in hospitals who don’t need to be there, said Eric Borgerding, the president and CEO of the Wisconsin Hospital Association.
“At any given day, Wisconsin hospitals have 400 or 500 patients that we cannot discharge,” Borgerding told Chief Healthcare Executive® in a February interview. “They no longer need to be in the hospital, whether it's private insurance, or Medicare or Medicaid. They're not paying for them to be in the hospital any longer because the reason they came to the hospital has been addressed.”
Typical delays can last days, he says, but some delays go weeks or longer.
“Some of these folks are in there for months,” Borgerding said. He added, “There are some that have been there for over a year.”
Ettore Palazzo, the CEO of EvergreenHealth, a community-owned, two-hospital system based in Kirkland, Washington, said at times in recent years, nearly a quarter of the hospital beds were occupied by patients who could be discharged. Those figures have improved a bit, but his system is still housing too many patients that don’t need to be in hospital beds, he said.
These patients “no longer had an acute care need to be in the hospital but there was no place for them to go to continue their post-acute care recovery,” Palazzo said in an online discussion last week.
“We’re caring for them, keeping them safe,” Palazzo said. “Of course, no more reimbursement is coming in for them.”
In Washington, the delayed discharges pose another problem. Washington state has the lowest number of hospital beds, per capita, in the nation, according to a KFF analysis. So if patients are staying longer than necessary due to delayed discharges, Palazzo said, “That effect on throughput, in getting those patients that are very ill and need that next level of care, can be incredibly challenging.”
Sauer, the head of the Washington State Hospital Association, also stressed that hospitals aren’t appropriate places for those who don’t need to be there.
“It's meant for acute care,” Sauer says.
For patients who are in the hospital awaiting discharge, the extended stay can be demoralizing.
“You don't get to be outside,” Sayer says. “You don't get to have social time with your friends … you're eating all your meals in the same room. So it's bad for hospitals, and it's bad for patients. And I think really emphasizing that point is important.”
When patients stay in hospitals due to delayed discharges, they face a greater risk of developing other health problems, Maiorano said.
“There's a toll that this takes on patients,” he said. “It's not just the time spent, but the time they spend in an acute setting adds complications potentially to their hospitalization, increases risks of secondary illnesses or infections in a hospital setting, as well as delays the ultimate care they need for the condition they have.”
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