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‘It feels like we just got them into Harvard’: The high-stakes mission to ease gridlock inside Mass. hospital emergency departments

Case manager Gail McCabe at Tufts Medical Center spends all day hunting for nursing homes and rehab centers that will accept her patients.Jessica Rinaldi/Globe Staff

Gail McCabe has gotten good at scrounging and pleading, hunting for places that will accept patients ready to be discharged from Tufts Medical Center. They need rehabilitation or long-term care, but few facilities have room for them.

To make matters worse, insurance companies that cover that care can take nearly a week to approve the transfers. That leaves patients who are well enough to move on stuck in the hospital, in many cases for a month or more.

“I am so excited when someone gets a bed. It feels like we just got them into Harvard,” said McCabe, a registered nurse at Tufts who focuses on finding patients follow-up care.


But as McCabe works the phones and confers with anxious families, new patients stream into the emergency department. Hospital ERs across Massachusetts are facing unprecedented backups as patients face hours-long waits for care, often admitted but still waiting on gurneys in hallways, because patients ready to be discharged can’t leave yet.

If hospitals, with their streams of incoming and outgoing patients, can be compared to busy roadways, then they are in a state of massive gridlock, with all their exit ramps backed up. Many nursing homes have such severe staffing shortages they are periodically closing doors to new patients — most often from hospitals — because they can’t handle any more. Other such post-acute-care facilities, such as rehabilitation centers, face similar hurdles.

“At the beginning of the pandemic, so many patients in long-term care died [that] it was easier to get a long-term-care bed,” McCabe said. “But now, it’s not the case.”

More than 880 “stuck” patients were awaiting discharge from Massachusetts hospitals in October, and roughly 60 percent of them – 534 people — were waiting for a placement in a nursing home, data from the Massachusetts Health & Hospital Association show. Of those needing nursing-home care, fully one-third had been waiting between one and six months.


At the same time, roughly 62 percent of the state’s nursing homes have been intermittently freezing out new admissions because of severe staffing shortages, data from Massachusetts Senior Care Association, the industry’s trade group, show.

“Direct-care staffing vacancies continue to be an extreme challenge for nursing homes, as we have close to 8,000 total vacancies as of the current quarter,” said Tara Gregorio, the association’s president.

The crisis has made for some sleepless nights, said Cailin Gallego, executive director at Alliance Health at Marina Bay, a 167-bed nursing home in Quincy.

“The stress of having to staff a facility when you don’t have the staff — it’s hard to even describe,” she said.

Competition for nurses and nursing assistants is fierce.

“Some people apply to 10, 15, 20 jobs, and they may not even show up to the interview,” Gallego said. “They may get the job and not show up for orientation. It’s a real struggle.”

The Baker administration last January launched an initiative to help ease the backlog of hospital patients needing short-term rehab in nursing homes. It sent state-funded nursing teams to 10 nursing homes, and the administration said the program has helped ease the bottleneck for more than 3,300 patients across the state.

Next month, the state plans to expand that program to an additional 10 nursing homes and has slated $11.25million for that expansion over the next year.


Gallego’s nursing home was tapped for the program in July, receiving four nurses and six nursing assistants. The additional staffing, Gallego said, has allowed her to continue accepting new patients.

But another major obstacle to timely discharges is the increasing amount of time hospitals are waiting for insurance companies to approve those transfers, or negotiating alternate care when insurance denies a proposed plan. Hospital administrators listed that as the most common hurdle last month in a survey by the Health & Hospital Association.

A report from the US Office of Inspector General in April found that insurers offering Medicare Advantage plans, used by millions of older adults nationwide, sometimes delayed or denied beneficiaries access to services, even though the requests met Medicare coverage rules. Denials or delays in transferring hospitalized patients to nursing homes and rehab facilities were among the most prominent problems they found.

The Massachusetts Health and Hospital Association singled out Medicare Advantage plans from insurers United Healthcare and Wellcare as posing the “greatest concern.”

In a statement, United Health said, “Getting people out of the hospital and into the right venue of care is a top priority for us and, on average, 87 percent of our decisions are returned to the provider in less than 12 hours.” The insurer added that the remaining 13 percent include in-patient rehab requests, which are often highly complex, and can take up to 47 hours for a response. On average, it said, about 20 individuals per month in Massachusetts can wait six days to receive approval, including time to process their appeal.


Wellcare did not respond to requests seeking comment.

Caryn Sullivan, director of social work at UMass Memorial Medical Center, said her team of 28 social workers, who help place patients into nursing homes or other types of care, are encountering time-consuming delays with all types of insurance coverage.

“Last week, two of my social workers were crying,” Sullivan said.

“The medical teams wanted the patients moving along, and they’re trying their best,” Sullivan said. “It’s defeating to work so hard, and not being able to move and feel like you’re running in place.”

Sullivan, who calls herself an optimist, said she tries to remind her colleagues of all their successes, too.

“It’s not just the discharges, but the level of care and compassion,” she tells them. “It’s what keeps our staff coming in every single day.”

Kay Lazar can be reached at Follow her @GlobeKayLazar.