Stuck in the hospital
Delayed discharges of medically stable patients are a problem that's not going away.
A subgroup of hospital patients is “lost in plain sight,” as ACP Member John Ratelle, MD, a hospitalist at Mayo Clinic in Rochester, Minn., puts it, and their numbers are growing. According to a study of 15 U.S. academic hospitals, more than a third of medical inpatients belonged to this population in fall 2022.
Similarly, more than 200,000 Veterans Affairs hospital patients faced the problem in 2023, according to research by Robert Burke, MD, MS, associate professor of medicine at the University of Pennsylvania in Philadelphia.
So what condition did all these patients share? They were medically ready for discharge but still in the hospital.
The study of academic hospitals, published by the Journal of Hospital Medicine (JHM) last year, sampled 1,928 inpatients on random Mondays, finding that 35% were medically ready to go and 9.8% had faced major barriers that had kept them in the hospital at least a week longer than medically necessary.
The most common reason that the studied patients lingered will come as no surprise to hospitalists: lack of skilled therapy or daily living support services.
“Nursing home access is number one, it seems like, far and away. That's both anecdotal and evidence-informed,” said Dr. Ratelle, who has previously studied the effects of patient-clinician disagreement on discharge delays.
Unlike patient communication, skilled nursing facility (SNF) access may feel like an issue out of hospitalists' control. “If there's not a skilled nursing facility bed available, then there's no bed available,” said Michael Pfeffer, MD, FACP, professor of medicine and chief information and digital officer at Stanford University in California.
But that doesn't mean there's nothing to be done. “As a hospitalist, I can't change the system and make more nursing home beds. So how do we make the most of what we've got? That's what I've become interested in,” said Dr. Ratelle.
He and other experts offered some of their answers.
On the increase
Demand for SNF care exceeded the supply and caused delayed hospital discharges before 2020, but the pandemic brought the situation to a head.
“It does feel like that aging baby boomer population is finally really manifesting itself in terms of the strain on the hospital system. I think COVID accelerated that and we haven't been able to get back to where we were before,” said Dr. Ratelle.
“We were starting to see a little bit of an uptick just prior to COVID, and when COVID hit, across the board, with staffing issues and all that, it just skyrocketed,” agreed ACP Member Jennifer Zagursky, MD, lead author of a recent JHM perspective on the subject, titled “Gridlock: What Hospitalists and Health Systems Can Do to Help.”
As Dr. Zagursky suggested, the most likely cause of the shortage of SNF care is thought to be a shortage of staff at these facilities. “The current SNFs that are out there are not at capacity,” said Dr. Burke, a coauthor of the gridlock article, one in a series. “The average occupancy rate now is 70-some percent. There's a lot of beds. They're just not being used.”
The problem of insufficient capacity for patients extends beyond SNFs, he noted. “This is revealing underinvestment in the supports that keep older adults in their homes. That's an inflow problem and an outflow problem [for hospitals],” Dr. Burke said.
Given the aging of the U.S. population, “this is a problem that is going to get worse before it gets better,” he added, offering the example of Japan, which faced this demographic shift before the U.S. “Before there was an investment in long-term care, half of the hospital beds were older adults, and a third of them were staying longer than a year.”
The analysis of U.S. academic hospitals only found one patient who had been waiting around for more than a year, but 29 were at more than three months. “That's a really long length of stay,” said Dr. Burke. “Trying to provide high-quality care for that long is difficult in a very fast-paced, high-churn setting.”
Care solutions
Some hospitalists are experimenting with ways to meet the challenge of providing optimal care for long-stay patients, however, and Dr. Zagursky, an associate professor at the University of Rochester in New York, is one of them.
“We're looking at how do we get people out of the hospital effectively and efficiently, but also how do we provide the best care while they're here?” she said. “We've tried to move a little bit to the mindset of ‘If they weren't in an acute care hospital and were at their next place, what are the services that would be provided?’”
At her hospital, medically stable patients are handled together; they are seen less often by hospitalists than the acutely ill, but they are discussed on rounds every day. “We make sure that we talk about all of these patients the same as we would all our other acute patients on interdisciplinary rounds, so we don't lose track of them,” Dr. Zagursky said.
Care for these patients focuses on issues that are commonly relevant, like deprescribing, immunizations, and goals-of-care decision making. “We do things that are in line with normal health maintenance for them,” she explained. “We try to make sure that their goals of care align with what they truly want and fill out those [medical orders for life-sustaining treatment], health care proxies, and [powers of attorney].”
Other tasks that are addressed for these patients include arranging (or even completing) any subspecialty follow-up care and compiling detailed discharge information. “As our population ages and we have more cognitive comorbidities, behaviors become a big part of this,” Dr. Zagursky said. “We keep a record of everything we tried, so when they do leave us, the outside facility knows, ‘There's no reason to try trazodone again,’ or ‘If you just get them a cup of coffee, they're happy.’”
Keeping patients happy when discharge is delayed is another frequent challenge, noted Dr. Ratelle, who visited a Canadian hospital that had focused on improving the experience of patients staying for weeks to months.
“They interviewed them and said, ‘What can we do to help you be more engaged with physical therapy, to get up and move, to sit?’ And they said, ‘Well, I'm bored and I'm lonely. I'm not going anywhere. I'm isolated, and I'd rather just lay the day away,’ which seemed like a pretty reasonable response.’”
The hospital, in turn, hired a recreational therapist to organize activities that would motivate the patients to move around and interact with others. “They didn't have quantitative data yet, but just in their qualitative experiences, it was night and day,” Dr. Ratelle reported.
In addition to adding interventions for these patients, hospitalists should think about removing some, advised Dr. Pfeffer. “First and foremost, you want to reduce iatrogenesis, eliminating lines and tubes, … turning off monitors. If the patient was going to be discharged, they probably don't need a cardiac monitor anymore,” he said.
A prolonged stay is also an opportunity to address a patient's chronic conditions, said Paula Chatterjee, MD, MPH, an assistant professor of general internal medicine and director of health equity research for the Leonard Davis Institute of Health Economics at the University of Pennsylvania.
“How good do I feel about this person getting outpatient follow-up as I would want them to?” she said. “If I am less confident about that, I will be more engaged in their care while they're waiting around for a SNF bed, like, ‘Let's optimize blood pressure control.’”
Ideally, all patients with delayed discharge would get this type of attention routinely instead of randomly, Dr. Chatterjee added. “You wonder if there's a way to streamline that ... Is there a structure or a system that we can optimize their care in a way that's less haphazard, perhaps, than what I find myself doing right now?” she asked.
Another thing that should be less haphazard is the relationship between hospital and SNF staff, said Dr. Burke. “To be totally honest, I think hospitalists don't know much about what's available to support older adults in the community. They don't know much about what happens in skilled nursing facilities.”
More knowledge can assist in the effort to get a SNF to take a patient, and some small steps by hospitalists can help forge a connection across the settings. “Sometimes it's as easy as coffee and donuts,” said Dr. Burke. “That can lead to very positive interactions, less driven by ‘Why aren't you taking our patients?’ or blame games.”
Learning more about what members of the interprofessional team within the hospital can provide is another way to optimize care for these patients, the experts said. “Recreational therapy was actually not a degree I was familiar with,” said Dr. Ratelle, noting one example. “It's recognizing that there are a lot of things we're not trained in as physicians.”
To remedy such knowledge gaps for the next generation of hospitalists, Dr. Zagursky's team includes residents and medical students in their care for medically stable patients. “When they are on the floors with us, they are getting taught … What are the barriers to discharge? What do we need to get the patient out? They're learning about the different levels of postacute care,” she said.
Broader change
To more significantly improve the situation for future clinicians and patients, policy changes are needed, and physician advocacy can improve the chances of those happening, the experts agreed.
“The stories that we see in front of us are powerful pieces of data that can be used to inform policymakers,” said Dr. Chatterjee. “A lot of effort has been dedicated to changing the local forces around hospital gridlock, problems that are within the locus of control of individual providers or hospitals or skilled nursing facilities. While that can get you part of the way, without zooming out and having this broader perspective, you end up just trying to reinvent the wheel.”
There is potential for policies and funding of postacute care to change on a national level, noted Dr. Burke. “Eliminating the three-midnight stay requirement, streamlining prior authorization, and Medicare Advantage really investing in home-based care services—there's these new possibilities,” he said.
Advocacy by hospitalists on issues surrounding postacute care is particularly important because the affected patients are unlikely to be able to push for improvements. “So much of the burden of this gridlock falls on structurally marginalized patient populations,” said Dr. Chatterjee.
Patients headed for a SNF are “a vulnerable population inherently,” said Dr. Ratelle. “They often don't have the social, cognitive, and physical resources to advocate for themselves.”
Hospitalists, on the other hand, are highly capable of banding together for improvement.
“You are not alone. Any frustrations you are feeling, somebody else has definitely felt,” said Dr. Zagursky. “Reaching out to colleagues and keeping up with the literature … everybody should really try to get things out. If it's not formally published, at least be active on forums or doing some networking. I have not run into one single person who has ever said, ‘Don't bother me about this.’ It's a team effort.”