Patients ready for discharge languish in New Hampshire hospitals, taking up needed beds • New Hampshire Bulletin

When public hospitals say they have problems front and back, this is what they mean.

On a single day in early June, 79 much-needed hospital beds were occupied by people who were ready to be transferred to a lower level of care but remained hospitalized because that care was unavailable. The reasons ranged from a lack of nursing home beds and a lack of legal guardians for those who needed them to long waits for Medicaid benefits to begin.

While some of the 79 patients spent only a few more days in the hospital, 45 of them had been waiting for discharge for more than 100 days. Five of them had been hospitalized for more than 300 days, one for more than 400 days, celebrating birthdays in their rooms.

In total, these 79 patients occupied beds they did not need for 7,455 days, according to New search by the New Hampshire Hospital Association. The situation is bad for patients and hospitals, which do not receive insurance payments for patients who are medically discharged.

Meanwhile, on the association’s June census day, there were 15 patients in the emergency room needing a hospital bed. That number tends to be higher during the winter months, when respiratory illnesses like the flu are more prevalent.

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

“Emergency departments are not designed for inpatient care, and staff are not accustomed to the routines of 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, hoping that identifying barriers to discharge would help the association, state leaders, lawmakers and others identify solutions. That has led to some small progress.

Where are the bottlenecks?

The Department of Health and Human Services is trying to simplify and speed up the process for getting Medicaid benefits. The state has spent federal pandemic aid on the benefits in hopes of increasing long-term care staffing and reopening closed beds. There has been some acknowledgement that the state needs to hire more legal guardians, though a bill to study that and other barriers to hospital discharge failed this year.

However, these measures have not led to the hoped-for progress, according to the New Hampshire Hospital Association.

The number of patients admitted to hospital and awaiting discharge fell last year, from 130 in September to 79 in June. But the number of extra “unnecessary” days during which some patients occupy a hospital bed increased.

In March, the association’s last report before June, 66 patients awaiting discharge to a nursing home spent an additional 60 days in hospital. In June, 46 patients requiring this long-term care spent an additional 72 days in hospital.

The numbers are even worse for patients awaiting discharge to long-term acute care facilities, which care for patients with more complex medical needs. New Hampshire does not have these facilities, the association says, forcing hospitals to look outside the state for facilities.

In March, three patients waited 42 more days for a bed in a long-term care facility. In June, three patients occupied a hospital bed they didn’t need for 175 more days. Similarly, the number of patients waiting for a legal guardian to make medical and other decisions decreased from 27 in March to 18 in June, but the median number of unnecessary days spent in hospital increased from 45 to 55.

Workforce shortages have plagued hospitals and long-term care facilities throughout the pandemic and were a driving factor in the association’s report. Of the 79 patients, vacancies in long-term care facilities forced 11 patients to stay in a hospital bed longer than necessary before being discharged.

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

While the latter has gained 20,000 jobs since just before the pandemic, hospitals have lost about 1,100 employees and nursing homes and other long-term care facilities are just above breakeven — at a time when demand for care is increasing, he said. That growing demand is driven in part by New Hampshire’s aging population. About 20% of Granite State residents are 65 and older, and another 15% are between 55 and 65, according to New search by the New Hampshire Fiscal Policy Institute.

Lavers said the unemployment data shows particular concern for employers in the long-term care sector.

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

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

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

“Compensation is still important, right?” Lavers said. “But all of these things that contribute to work-life balance are becoming more important.”

Employees want to be able to change their schedule and go to their child’s soccer game or pick them up from school. Others want to work remotely at least some of the time. “I think all of those things have really become more important in how individuals evaluate their workplace,” Lavers said.

The New Hampshire Hospital Association found that other significant factors contributing to discharge delays included patients with complex conditions requiring individual care, insurance coverage and housing issues.

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

Lack of insurance or delays in getting benefits played a role for patients covered by commercial and federally subsidized plans. Medicaid was a particular problem, followed closely by Medicare, the report said.

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

Working towards 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 speed up the benefits approval process, which is cumbersome because an applicant must provide dozens 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 paid to include legal guardians and people with legal authority to make medical decisions.

The department asked CMS to allow it to grant “presumptive eligibility” for Medicaid when the department believes a person is likely to receive benefits. Presumptive eligibility would allow benefits to begin while a person’s application is still pending.

However, the department’s request only applies to in-home services under the Choices for Independence program, which allows a person who needs help with daily living tasks, such as showering and cooking, to stay out of institutions, including nursing homes.

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

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

Additionally, Santaniello said the state is strengthening its disability and senior resource centers to better help people apply for Medicaid or transition from a hospital to a nursing home or other community facility. Other initiatives include collaborating with experts in other states on ideas to alleviate workforce challenges.

Santaniello stressed the department roadmap describing its planned investments to improve care.

“This is not just about our long-term services and supports division,” Santaniello said. “This is a priority within the department because we recognize that we need to ensure that seniors have effective and timely access to services.”