On a recent Tuesday morning, the Brigham and Women’s Hospital emergency department was overflowing with patients. Suffering people lay on stretchers in the hallways and next to nurses’ stations. Staff tried to give rooms to people who had an infectious disease or needed an exam. The emergency department has 59 acute care beds, and there were an additional 74 patients. Many were ready for hospital admission but waiting for an inpatient bed.
The problem — an increasingly common one across Massachusetts — was that inpatient beds were also backed up. On the hospital floors the prior Friday night (the most recent data available), Brigham had 42 patients who were medically cleared to leave but could not be discharged, taking up beds that those patients lining the halls at the ED could have used. The 42 patients generally needed more care from a rehabilitation center, skilled nursing facility, or home health service. The hospital might have been waiting for insurance approval or for a bed to open up. On average, about 7 percent of patients in the Mass General Brigham system, approximately 150 patients a week, no longer need to be there.
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The bottleneck means patients get stuck in the emergency department and the hospital cannot accept transfers of people who need acute inpatient care. Hospitals are paid for each patient stay rather than a daily rate, so hospitals lose money if patients stay longer than expected. Most importantly, patients are stuck in bed, not getting the rehabilitation they need.
The problem of delayed discharges has gotten worse since COVID-19-related staffing challenges and closures reduced capacity in rehabilitation facilities.
The Massachusetts Health and Hospital Association issued a June 2023 report, which found that between March 2022 and February 2023, 50 hospitals reported an average of 1,057 medical-surgical patients awaiting discharge at any one time, leaving 1 in 7 acute medical beds tied up with someone who did not need to be there. A majority were seeking admission to skilled nursing facilities.
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The most common reason cited for delays, according to the MHA report, is administrative barriers from private insurance companies. Insurers who need to approve a transfer would delay responding or deny a request.
The second most common reason was staffing or capacity constraints. The Massachusetts Senior Care Association estimates there are about 7,400 vacant direct care positions at Massachusetts nursing homes, around 1 in 5 positions. Twenty nursing homes closed since the pandemic started, according to MHA.
The third reason was the lack of a guardian or health care proxy for patients incapable of making decisions.
Carl Jean’s experience highlights the challenges caused by administrative delays. According to his daughter, Stephanie Guerrier, a medical assistant from Boston, Jean, an 81-year-old Haitian immigrant, was hospitalized at Beth Israel Deaconess Medical Center in November 2022 following his third stroke. He was insured by MassHealth, which would have covered his stay at a rehabilitation facility. But Guerrier did not know her father’s Social Security number, without which several facilities rejected him. Two weeks after Jean was admitted, hospital officials started looking into rehab, but he remained hospitalized for the three months it took Guerrier to find a lawyer through Health Law Advocates, which offers free health-related legal services, get power of attorney, and obtain her father’s Social Security number. He was finally released to a Watertown rehabilitation facility, where he died in April.
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“The nurses in the hospital were like, when is he leaving? There was nothing more they were going to do for him,” Guerrier recalled.
There is no silver bullet solution, and hospitals, nursing homes, insurers, and policy makers all have roles to play in addressing the problem.
Brigham and Women’s Hospital improved its patient flow through adjustments like planning for discharge early and having case management staff focused on the most complex patients so referrals are made earlier and issues like guardianship and transportation are resolved. State government has set up a hotline to help hospitals manage hard-to-place patients.
Hospitals have experimented with services to help patients return home — providing physical therapy visits or partnering with elder service agencies to install shower bars or coordinate food deliveries. The federal government should approve MassHealth’s request to cover short-term medically supportive housing for homeless individuals.
State policy makers should also look at proposals to boost staffing at skilled nursing facilities. To its credit, MassHealth has increased reimbursement rates for units that treat medically complex patients — like those on dialysis or with mental health or substance use disorders — and it is seeking industry input on what staffing and rates would be necessary to add beds in specialty fields like bariatric and dementia care. Today, hospitals say few units accept patients who require more intensive services. Nursing homes should consider participating in a state program allowing them to host dialysis centers — so far, two started offering it and 11 are working on it.
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State and federal officials could consider continuing pandemic-era flexibilities like letting nursing students start working before completing exams or waiving a rule that requires someone to spend three nights hospitalized before Medicare pays for rehabilitation.
Finding ways to raise salaries, repay student loans, or provide career advancement paths for long-term care workers could enhance retention.
Courts should consider expediting guardianship proceedings for hospitalized patients.
Lawmakers are considering reforms to insurers’ prior authorization policies, in which insurers need to approve medical care — whether a medication or a stay in a rehabilitation facility — before it can be delivered, to ensure the insurance company will be willing to pay. Prior authorization is an important tool to ensure patients are sent to an appropriate level of care, but it causes delays. All parties need to ensure that hospitals give insurers adequate information, insurers expedite approvals of hospitalized patients, including to out-of-network providers, and nursing facilities respond quickly to accept patients.
Entering the respiratory illness season when hospitalizations spike, doing everything possible to move patients out of hospitals quickly will be vital to ensure hospitals have capacity to care for the sickest people.
Editorials represent the views of the Boston Globe Editorial Board. Follow us @GlobeOpinion.