Patients ready for discharge in NH hospitals take up needed beds

When New Hamsphire’s hospitals say they have problems at the front and back doors, this is what they mean.

On a single day in early June, 79 much-needed hospital beds were occupied by people who were ready for discharge to a lower-level of care but remained hospitalized because that care wasn’t available. Reasons ranged from a shortage of nursing home beds and too few legal guardians for those who needed them to long waits for Medicaid benefits to start.

While some of the 79 people spent only a few extra days in the hospital, 45 had been awaiting discharge for more than 100 days. Five of those had been there more than 300 days, one for more than 400, marking birthdays and anniversaries in their rooms.

Together those 79 patients had been taking up beds they didn’t need for a total of 7,455 days, according to new research by the New Hampshire Hospital Association. The situation is bad for patients and hospitals, which do not receive insurance payments for patients medically cleared for discharge.

Meanwhile, on the day of the association’s June count, 15 patients sat in emergency rooms needing a hospital bed. That number tends to be higher in winter months when respiratory illnesses like the flu are more prevalent.

While patients can be stabilized and kept safe in an emergency room, it’s not the best place to receive care, experts said.

“Emergency departments are not designed for inpatient care and staff aren’t used to the routines for inpatient therapies and medications,” said Kris Hering, vice president of quality improvement at the Foundation for Healthy Communities.

The New Hampshire Hospital Association began tracking delayed discharges nearly a year ago with hopes that identifying barriers to release would help the association, state leaders, lawmakers, and others identify solutions. That’s led to some small steps.

Where the bottlenecks are

The Department of Health and Human Services is attempting to simplify and speed up the process for securing Medicaid benefits. The state put federal pandemic aid toward stipends hoping it would expand the long-term care workforce and reopen closed beds. There has been an acknowledgment that the state needs to recruit more legal guardians, though a bill to study that and other discharge barriers failed this year.

Those steps, however, have not led to the progress hoped for, according to the New Hampshire Hospital Association.

The number of medically-cleared patients awaiting discharge has dropped in the last year, from 130 in September to 79 in June. But the number of extra “unnecessary” days some patients are occupying a hospital bed has increased.

In March, the association’s most recent report prior to June, 66 patients awaiting discharge to a nursing home had spent an extra 60 days in a hospital. In June, 46 patients in need of that long-term care spent 72 extra days in a hospital.

The numbers were worse for patients awaiting discharge to long-term acute care settings, which care for patients with more complicated medical needs. New Hampshire does not have those facilities, according to the association, leaving hospitals to look outside the state.

In March, three patients spent an additional 42 days awaiting a bed in an acute long-term care setting. In June, three patients had taken up a hospital bed they didn’t need for an extra 175 days. Similarly, the number of patients awaiting appointments of a legal guardian to make medical and other decisions dropped from 27 in March to 18 in June, but the median number of unnecessary days they spent in the hospital grew from 45 to 55.

Workforce shortages have plagued hospitals and long-term care settings throughout the pandemic and were one of the drivers in the association’s report. Among the 79 patients, staff vacancies at long-term acute care facilities had kept 11 patients ready for discharge in a hospital bed longer than needed.

Richard Lavers, deputy commissioner at the state Department of Employment Security, said hospitals and long-term care facilities have not seen the post-pandemic job recovery the private sector has.

Where the latter gained 20,000 jobs since just before the pandemic, hospitals are down about 1,100 employees and nursing homes and other long-term care settings are just above breaking even – at a time when demand for care is increasing, he said. That growing demand is due in part to New Hampshire’s aging population. About 20 percent of Granite Staters are 65 and older and an additional 15 percent are between 55 and 65, according to new research by the New Hampshire Fiscal Policy Institute.

Lavers said that unemployment data shows a particular concern for long-term care employers.

Of the 2,600 workers who filed for unemployment at some point during the pandemic, 40 percent left the health care field when they returned to the workforce. Twenty-five percent left long-term care for another health care field, such as ambulatory care including primary practices. That sector has seen a significant growth in workers, Lavers said.

The biggest losses were among younger workers ages 20 to 29, who likely took new jobs, Lavers said, and older workers between 60 and 69, who chose to retire or otherwise leave the workforce.

Lavers’ team has worked closely with health care providers throughout the pandemic to identify why employees are leaving jobs and what they need to return. Lavers has urged employers to consider the flexibility that private employers can offer, though he knows that’s harder to do in settings that provide 24-hour, in-person care.

“Compensation is always important, right?,” Lavers said. “But rising in the level of importance is all of those things that go into work-life balance.”

Employees want the flexibility to shift hours and make it to a child’s soccer game or pick kids up after school. Others want to work remotely at least some of the time. “I think all of those have really grown in importance in terms of how each individual evaluates where they want to work,” Lavers said.

The New Hampshire Hospital Association found that other big contributors to delayed discharges included patients with complicated illnesses who require one-to-one care; insurance coverage; and housing concerns.

For example, 22 patients spent extra days in the hospital because they had no family or friends willing or able to help them after discharge. Seven patients were homeless, with a median discharge delay of 72 days.

The lack of insurance or delays in initiating benefits played a role for patients covered by commercial and federally-subsidized plans. Medicaid was a particular problem, with Medicare close behind, according to the report.

The median number of extra days for patients awaiting approval of Medicaid benefits to enter nursing homes was 150; for long-term acute care facilities, it was 395 days.

Working toward solutions

Chris Santaniello, associate commissioner at the Department of Health and Human Services, said the department has made several changes intended to expand Medicaid eligibility and move along the benefit approval process, which is cumbersome because an applicant must provide scores of financial documents that may not be readily available.

The department worked with the Centers for Medicare and Medicaid Services to expand the types of caregivers who can be compensated to include legal guardians and people with legal authority to make medical decisions.

The department has asked CMS to allow it to grant “presumptive eligibility” for Medicaid when the department thinks someone is likely to be approved for benefits. Presumptive eligibility would allow benefits to begin while an individual’s application is pending.

However, the department’s request is only for in-home services through the Choices for Independence program, which allows someone who needs help with daily living tasks like showering and cooking to remain out of facilities, including nursing homes.

The state has not made the same request for nursing homes and other post-discharge settings, something hospital advocates believe could make a significant difference.

The state budget also allowed the department to increase Medicaid payments to agencies that provide that in-home, non-medical care. Santaniello said one agency was able to hire enough new staff to begin caring for the 200 people on its waitlist. Another provider increased its staff enough to add 2,000 hours of care a month for clients, she said.

In addition, Santaniello said the state is enhancing its disability and aging resource centers to provide individuals more assistance in applying for Medicaid or transitioning from hospitals to a nursing home or other community-based setting.  Other initiatives include collaborating with experts in other states on ideas for mitigating workforce challenges.

Santaniello pointed to the department’s road map outlining its planned investments to improve care.

“It’s not just within our division of long-term supports and services,” Santaniello said. “This is front and center within the department, recognizing that we need to ensure older adults have effective and timely access to services.”

This story was originally published by the New Hampshire Bulletin .

This article originally appeared on Portsmouth Herald: Patients ready for discharge in NH hospitals take up needed beds