Hospitals report over 1,000 patients awaiting discharges with nowhere to go 

AT UMASS MEMORIAL MEDICAL CENTER in Worcester on Monday, there were 63 patients stuck in the emergency room waiting for an inpatient hospital bed to open up. Meanwhile, there were 80 patients on inpatient units who were ready to leave and give their beds to someone else. But the hospital could not discharge them safely, so they stayed. 

Some people were waiting for an inpatient psychiatric bed. Others had complex medical needs and were waiting for a nursing home or long-term care bed. A few were waiting for court proceedings to appoint a guardian. Some did not have legal immigration status and lacked insurance to cover rehabilitation or home care. 

“It’s the worst I’ve ever seen,” said Kim Barry, vice president and associate chief nursing officer at UMass Memorial Medical Center, of the capacity crunch. 

UMass Memorial’s situation is not unique right now. A survey released Monday by the Massachusetts Health and Hospital Association found that at any given time there are approximately 1,000 hospital patients who are ready to be discharged, but cannot be because there is nowhere for them to get follow-up care. These patients may need a nursing home bed, rehabilitation hospital, or home health agency, but they are unable to access that care. The result is a bottleneck in which patients are stuck in a more intensive and more expensive care facility than they need, while hospitals cannot free up beds for patients who need acute care. 

The problem comes on top of the “boarding crisis” facing mental health patients, in which patients are waiting in emergency rooms for hours or even days for a psychiatric care bed to become available. The state hospital association’s latest report on boarding found that as of last Monday, there were 660 patients waiting at 53 hospitals for a psychiatric bed – people not included in the count of more than 1,000 awaiting discharge who need medical follow-up care. 

Together, these two crises point to a struggling health care system, in which hospitals are becoming overloaded due to a lack of capacity elsewhere and patients are stuck in hospitals far longer than they need to be. 

“It’s really a disservice to patients that are waiting for that specialty care,” Barry said. 

The MHA survey received responses from 44 hospitals about their patient population at a point in time in May 2022. The hospitals identified 1,066 patients awaiting discharges. The bulk of them – 672 – needed nursing home level care, representing a significant increase in patients seeking that level of care over the past three months. The need was for a mix of short-term and long-term beds, along with smaller numbers of specialized beds, like those that can serve dementia patients or patients with substance use disorders. 

Another 289 patients needed home health care and 105 needed a bed at an inpatient rehabilitation hospital or long-term acute care facility. Both those numbers have decreased over the last three months. 

The length of time patients waited varied widely. The hospitals documented 220 patients who had to wait between seven and 13 days. Another 183 patients, including 162 awaiting a nursing home bed, had to wait between 30 days and six months. 

Geographically, the biggest concentration of patients was in the Metro Boston area, but they spanned the state. Most had public insurance, either Medicare or Medicaid. 

The report identified several factors as barriers to discharge. One of the most common was a lack of insurance. Either a private insurer delayed responding or denied a coverage request, or the person did not have insurance coverage for the care they needed. A lack of staffing or capacity at facilities was another barrier. Sometimes a person needed a legal proceeding to name a guardian who could make their health care decisions, and sometimes a patient needed a specialized service, which was unavailable.  

“There’s no single dominant reason for discharge delays,” said Adam Delmolino, director of virtual care and clinical affairs for MHA. “Care providers are reporting a true mix of factors.” 

Some factors are directly COVID-related. Some nursing homes and rehabilitation facilities will not accept patients who are not vaccinated against COVID-19, and others require an additional quarantine for unvaccinated patients. The report found that 71 patients waiting for care were unvaccinated. There were also 57 patients who had to wait to be admitted somewhere because they had COVID-19. 

Delmolino said demand for post-acute care is greater than it used to be because people are sicker when they come into the hospital, whether because of COVID or because of delayed care for other ailments. If a COVID surge leads to a backlog of patients, it takes time to chip away at that backlog. 

Tara Gregorio, president of the Massachusetts Senior Care Association, which represents nursing homes, said the biggest problem preventing nursing homes from taking more patients is a lack of staffing, which can be traced to a lack of funding. 

“This is a product of our ongoing and historic workforce crisis,” Gregorio said. 

Gregorio said nursing homes have used increased Medicaid rates and one-time COVID recovery money to raise workers’ wages. A certified nursing assistant earns 19 percent more in 2022 than in 2019. But the base rates nursing homes are paid from Medicaid have only gone up 4.5 percent, so with supplemental state money set to expire this month, Gregorio said she worries nursing homes won’t have enough money to retain staff. 

As of January, Gregorio said nursing homes had 7,000 vacant positions statewide, a figure that dropped to 6,600 in April. She worries the vacancy rates will rise without more supplemental funding. And even in April, 70 percent of nursing homes reported intermittently pausing admissions due to inadequate staffing. “Quite frankly, I think this crisis will only expand moving forward,” she said. 

Gregorio said her association has been working with the state to address particular problems – for example, changing state regulations to let nursing homes set up dialysis centers so they can more easily accept dialysis patients. But she said it comes down to money. “We ultimately need a reimbursement system that recognizes the cost of our workforce,” Gregorio said. 

Delmolino said the Baker administration and industry groups have made efforts to address the problems. The Executive Office of Health and Human Services has a discharge team that helps hospitals find placements for complex patients, like bariatric patients who need specialized equipment. The state contracted with two nursing facilities in each of five regions of the state for a temporary program to provide short-term rehabilitation space. Delmolino said that program will operate through this summer. 

“We’re exploring the longer term set of solutions now,” Delmolino said.  

But Delmolino warned that while workforce shortages may be the most acute problem, there are a range of issues that must be addressed, from medical transportation to insurance obstacles. “There’s not one silver bullet, there’s not one solution,” Delmolino said. “It’s a multi-factor effort we’ll all have to work on together.”