Over a thousand patients have been ‘stuck’ in hospital beds as discharge problems persist

Over the past year, an average of 1,200 people were stuck in Massachusetts hospital beds each day because workers could not find a place to discharge them, a new report says, in the latest sign that hospitals continue to struggle with overcrowding even as the COVID pandemic has ebbed.

The patients occupied approximately 15 percent of the state’s staffed medical and surgical hospital beds, according to data from March 2022 through February this year, creating backups in emergency rooms as other patients waited to be admitted.

“Even as the public health emergency has come to an end, our health care system is still in major distress,” said Steve Walsh, president and CEO of the Massachusetts Health & Hospital Association, which released the report Monday. “This backlog of stuck patients is playing a major role in driving up wait times and obstructing access to care.”

The crowding has eased somewhat in recent months, but large percentages of patients are still waiting to be discharged for more than 30 days. The bottlenecks have operational and financial implications, creating delays for ambulances to offload patients into the hospital, as emergency departments are full of patients waiting for an available bed. Some patients have had elective procedures postponed due to overcrowding.

Elective procedures are often the most profitable for hospitals, and delays scheduling them can hurt revenue. Hospitals are also the most expensive place for a person to receive care, and for hospitals committed to caring for patients on a predetermined reimbursement, additional time in the hospital can eat into that payment.

“That patient doesn’t need to be there anymore and is probably being harmed,” said David E. Williams, president of the consulting firm Health Business Group. “If you’re in the hospital, you’re more likely to get an infection. It’s more costly. And the patient who needs to get into that bed can’t.”

A variety of factors — in many cases exacerbated by the pandemic — are preventing hospitals from discharging patients more quickly. The new MHA report cites insurance delays and denials as the No. 1 barrier, followed by staffing shortages at nursing homes and rehabilitation centers.

In other cases, patients lack family guardianship or conservatorship agreements and cannot make decisions on their own. Others have needs that exceed what typical nursing home facilities can manage, or medical needs that extend beyond what psychiatric facilities can accommodate.

“Hospital case managers are spending endless hours and dozens of phone calls trying to get patients to the next level of care they need,” said Amanda Ford, director of continuity of care at Lowell General Hospital. “But the obstacles have become so numerous and so intense that it sometimes feels like an impossible task.”

The report does not include most of the 511 psychiatric patients who are forced to wait in emergency departments for a placement at a psychiatric facility, which also have limited beds due to staffing shortages.

The discharge problems have compounded a number of pandemic-induced stressors on hospitals, including staffing shortages that have forced hospitals to hire expensive temporary labor, as well as escalating supply costs.

Some of the patients who languish in hospital beds end up waiting for weeks or months to be discharged, a trend that has held true even as the number of people waiting for to be discharged has started to improve.

“This is not a unique phenomenon to Massachusetts or to any particular organization,” said Adam Delmolino, director of virtual care and clinical affairs at the Massachusetts Health & Hospital Association. “It is being felt across our state and country.”

Reasons behind the insurance delays include that many insurers don’t have adequate numbers of nursing homes and rehabilitation facilities within their network and are reluctant to transfer patients outside their networks. Some insurers have begun using artificial intelligence to determine length of coverage for treatments — decisions MHA called “arbitrary.” Other insurers have third-party vendors determine medical necessity and provide little oversight for those decisions.

While Massachusetts-based insurers waived many of the administrative barriers to discharging patients last year and early this year, not all have continued such practices. Such “prior authorizations” — administrative approvals before a patient can be transferred — remain a barrier.

Staffing in nursing homes remains an additional challenge. An April 2023 survey by the Massachusetts Senior Care Association found there are 3,000 licensed but unstaffed nursing home beds in Massachusetts, and that one out of every five positions in nursing homes is currently unfilled.

There are also fewer beds. In total, 20 nursing facilities in Massachusetts have closed since the start of the pandemic, also largely because of staffing problems, according to the report.

The state has worked with hospitals to respond, providing funding to support a temporary program to add short-term rehabilitation capacity throughout Massachusetts. When hospitals and skilled nursing facilities can’t find a place for a patient, they coordinate through a state hospital discharge ombudsman for help.

But the hospital group is advocating for more resources, including a program similar to one the state created for short-term rehab beds but focused on adding long-term care beds, placements for patients with dementia, and services for geriatric patients with psychiatric diagnoses.

Hospitals also want to build off a pilot program that embeds case managers in hospitals to provide so-called wrap-around services — such as meals assistance, medication assistance, and transportation help — that patients need to be discharged home.

“We saw a tremendous level of collaboration across health care throughout COVID-19, and it will take that same level of focus to resolve capacity issues,” Walsh said.