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October 5, 2022

Why hospitals are struggling to discharge patients—sometimes for months

Daily Briefing

    Due to severe staffing shortages at post-acute care facilities, many hospitals are struggling to discharge patients, leading to months-long delays and increased costs, Ginger Christ writes for Modern Healthcare.

    Post-acute care facilities are facing severe staffing shortages

    According to industry experts, skilled nursing facilities (SNFs) and home health agencies (HHAs) have been hit the hardest by staffing shortages throughout the pandemic, which has led to significant "bottlenecks" in hospitals waiting to discharge these patients, Christ writes. In some cases, patients who are waiting to be discharged to post-acute care facilities face months of delays as hospitals struggle to find an open placement.

    According to federal data analyzed by WellSky, the rejection rate in SNFs reached 88% in the first quarter of 2022, while the rejection rate in HHAs reached 71% in the second quarter of 2022. In addition, a survey from the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) found that 61% of its members were limiting admissions due to staffing shortages.

    When discharges are delayed, many patients have to remain in the hospital, taking up inpatient beds and costing hospitals and health systems money. "I liken it to traffic. You hit the roadblock, and everything else just comes to a grinding halt," said Heather Thompson, patient care executive at Adventist Health Tillamook in Oregon.

    To improve this situation, Holly Harmon, SVP of quality, regulatory, and clinical services for AHCA/NCAL, said post-acute care facilities will need more funding from Medicaid and increased support for training programs.

    "Nursing home providers have been doing everything they can to recruit and retain staff, but with fixed government resources, we cannot resolve this crisis on our own," Harmon said.

    How hospitals are improving their discharge processes

    To address this growing problem, many hospitals and health care systems are working to improve their discharge processes, performing insurance authorizations in-house, and paying facilities to take patients.

    For example, Corey Leber, associate VP of nursing and patient care services at ProMedica Toledo Hospital, said the organization is reassessing its discharge processes to remove potential barriers. So far, it has reassessed who is included in daily transition rounds and moved a director to a capacity management role so they can focus on efficiency.

    At Indiana University (IU) Health, officials last November started a pre-authorization process for post-acute care discharges with four insurance companies. According to Adria Grillo-Peck, VP of integrated care management at IU Health, the pre-authorization process with these payers now takes eight hours, down from the 48 to 72 it took before the change.

    This move has allowed the IU Health to save 3,600 days, backfill 682 beds, and achieve more than $10 million in savings. Currently, the system handles around 17% of its pre-authorizations, but Grillo-Peck said it plans to work with two more insurers to increase that number.

    To increase discharge rates for post-acute care patients, Sommer Kleweno Walley, CEO of the University of Washington Medicine's Harborview Medical Center, said the hospital has given post-acute care facilities additional payments to help them hire more staff to care for patients.

    "We pay, per individual, an enhanced payment on top of what [facilities] get from insurance," Kleweno Walley said. Although these payments cost the hospital $8 million in the last fiscal year, it has also benefited from freeing up bed space.

    In addition to these payments, Harborview also sends members of its post-acute care team, which includes physicians, NPs, social workers, and behavioral health specialists, to help patients at the facilities at no charge. "It gives [post-acute facilities] the medical expertise and support they need," Kleweno Walley said.

    State hospitals associations are also helping coordinate care

    According to Christ, some state hospital associations, as well as local government agencies, have also stepped into help reduce delayed discharges on behalf of their members.

    For example, Washington's Department of Social and Health Services (DSHS) last year began offering $6,000 admission incentive payments to SNFs, as well as smaller payments to HHAs, to help patients transition out of hospitals more easily.

    The Washington State Hospital Association is now trying to get DSHS and the Washington State Health Authority to speed up their authorization process for patients staying in post-acute care facilities.

    Elsewhere, the Massachusetts Health & Hospital Association (MHHA) in February partnered with state hospitals and the Massachusetts Senior Care Association to form a post-acute care transitions collaborative. So far, the collaborative has helped facilitate over 200 referrals, though MHHA said it did not have placement numbers.

    The Massachusetts Department of Public Health this spring launched a short-term rehabilitation program, which sent state-contracted nursing teams to post-acute facilities to help them care for patients. According to Adam Delmolino, director of virtual care and clinical affairs for MHHA, this effort has helped discharge roughly 1,300 patients.

    However, even with these efforts, Delmolino said that many hospitals in the state are still seeing a significant backlog of patients waiting to be discharged. As of May, 1,066 patients from 44 Massachusetts hospitals were waiting to be discharged to post-acute care facilities.

    "The need has been so great for our hospitals to find placements for our patients," Delmolino said, but "the number of patients who fall into that bucket continues to increase." (Christ, Modern Healthcare, 10/4)

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