Battling bottlenecks: Post-acute staffing shortages cause months of hospital discharge delays

On any given day, social workers and case managers at Adventist Health Tillamook call 15 to 20 post-acute care facilities trying to place patients ready to be discharged. Some facilities say they can’t accept new residents. Others don’t pick up the phone.

“A lot of time is wasted in looking for facilities to try to take patients,” said Heather Thompson, patient care executive at the Oregon critical access hospital.

The discharge process has never been easy, Thompson said. Hospitals need to match patients with facilities that can provide the right type of care, are covered by insurance and, in recent years, that accept a patient’s vaccination status. Staffing shortages throughout the long-term care industry have made placing patients even more challenging.

Across the country, hospitals are dealing with bottlenecks as patients who are ready to move on to post-acute care sites such as skilled-nursing, rehabilitation or assisted-living facilities are forced to stay in inpatient beds, costing health systems money.

“I liken it to traffic. You hit the roadblock, and everything else just comes to a grinding halt,” Thompson said.

In response, healthcare systems have had to get creative: bringing insurance authorization processes in-house, streamlining their discharge processes and paying facilities to take patients.

Experts say skilled-nursing facilities and home health facilities have been hit the hardest by staffing troubles. The healthcare technology company WellSky analyzed data from federal agencies, more than 1,000 hospitals and 130,000 post-acute care providers on referral rejection rates, which measure how often post-acute care facilities deny admission to patients being discharged from the hospital.

In the first quarter of 2022, the rejection rate in skilled-nursing facilities climbed to 88%. For home health providers, the rate increased from 49% in the second quarter of 2020 to 71% in the second quarter of 2022.

The American Health Care Association/National Center for Assisted Living found in a May survey of members that 61% were limiting admissions because of staffing shortages. In a June poll of members, LeadingAge, an association that represents 5,000 aging-services providers, found that of its respondents, 95% of nursing homes, 86% of life plan communities, 80% of assisted-living facilities and more than half of affordable senior housing providers reported significant or severe worker shortages.

Rodney Rueter, president and CEO of Lutheran Sunset Ministries in Clifton, Texas, said the facility’s problems filling jobs started to become more severe last year.

“There are no applicants. People aren’t even trying to come work here, and we’re losing people,” he said.

The assisted-living and long-term care facility has increased pay for nearly all hourly staff by 20% to 25% to attract and retain workers, but still can’t compete with other industries on wages, he said. Even with the pay increases, certified nursing assistants start at $13 per hour. Lutheran Sunset Ministries has 155 employees, which is about 20 fewer than before the pandemic.

As a result, the facility has had to turn away patients when health systems call. “The hard thing is, in a rural area, you know almost everyone [who would be] coming in,” Rueter said.

Having to deny care to “someone you’ve known almost your entire life, it’s just heartbreaking to do that,” he said.

To address staffing issues, post-acute care facilities will need government resources, including increased Medicaid funding and support of training programs, said Holly Harmon, senior vice president of quality, regulatory and clinical services for AHCA/NCAL.

“Nursing home providers have been doing everything they can to recruit and retain staff, but with fixed government resources, we cannot resolve this crisis on our own,” Harmon said.

Download Modern Healthcare’s app to stay informed when industry news breaks.

The post-acute care bottleneck presents a financial concern for health systems. Generally, hospitals don’t receive payments for patients beyond the number of days recommended by their insurance provider for their condition.

ProMedica Toledo Hospital in Ohio calls such extra time, sometimes known as lost-bed days, “opportunity days”—and it’s focused on reducing them, said Corey Leber, associate vice president of nursing and patient care services.

The hospital is reassessing its discharge processes to find ways to improve, Leber said. It has identified the role each worker plays, reassessed who is included in daily transition rounds and moved a director into a capacity management role to focus on efficiency.

“At any point where a patient enters or leaves the system, there’s an opportunity for barriers,” Leber said.

One such barrier is getting insurer approval for post-acute care. Often left to staff members at receiving facilities, the task can introduce more slowdowns. ProMedica’s hospitals in Michigan have for years handled preauthorization in-house; ProMedica Toledo is exploring how to implement a similar strategy. It plans to hire a few workers responsible for sending referrals to insurance companies and to adopt the same platform the post-acute facilities use for approvals.

Indiana University Health in Indianapolis started its own preauthorization process with four insurance companies for post-acute care discharges last November. In preparation, it hired three people and moved two existing staff to its precertification team. A process that historically took 48 to 72 hours was cut to eight hours for patients with those payers, said Adria Grillo-Peck, vice president of integrated care management for IU Health. The move saved the system 3,600 days, allowed it to backfill 682 beds and represented more than $10 million in savings.

Right now, IU Health handles about 17% of its preauthorizations. The system plans to start working with two more insurers to increase that percentage, Grillo-Peck said.

Beyond accelerating the approval process for patients, IU Health also leans on an established network of 43 long-term care providers with good quality and patient satisfaction scores and low readmission rates.

“That collaboration has made it a little easier to call in a favor because we’ve built these relations with these post-acute partners,” Grillo-Peck said.

Relationships have also been key at University of Washington Medicine’s Harborview Medical Center in Seattle.

As a county safety-net hospital and a Level 1 trauma center, Harborview typically has a lot of complex patients waiting to be discharged into long-term care, said CEO Sommer Kleweno Walley. It is licensed for 413 beds, but has been filling more than 500 throughout the public health emergency, with about 100 patients waiting for post-acute facilities.

Some take months to find a placement.

“Even pre-pandemic, when we had more bed availability in the facilities, we still had a hard time placing Harborview patients because of their complexity, and now it’s just magnified,” Kleweno Walley said.

For the past three or four years, the hospital has given post-acute care facilities additional payments to help hire the staff needed to care for patients.

“We pay, per individual, an enhanced payment on top of what [facilities] get from insurance,” Kleweno Walley said.

Last fiscal year, those payments cost the hospital $8 million—but the organization benefited from freed-up bed space.

The hospital also sends members of its post-acute care team into facilities at no charge to help with patient care. The team includes physicians, nurse practitioners, social workers and behavioral health specialists, all of whom Harborview hires specifically for that purpose.

“It gives [post-acute facilities] the medical expertise and support they need,” Kleweno Walley said.

Some state hospital associations are stepping in to try to address the problem on behalf of members.

In Massachusetts, post-acute care discharges can be delayed for months, said Adam Delmolino, director of virtual care and clinical affairs for the Massachusetts Health & Hospital Association.

The association teamed up in February with state hospitals and the Massachusetts Senior Care Association, representing long-term providers, to form a post-acute care transitions collaborative. Through the collaborative, the association shares information on complex cases from its hospital members with Mass Senior Care, which then identifies nursing homes or other post-acute facilities or home care agencies that might be able to take those cases. While the efforts have helped facilitate more than 200 referrals, the association said it did not have data on placements.

The Massachusetts Department of Public Health also launched a short-term rehabilitation program this spring, through which it sent state-contracted nursing teams to facilities to help them care for more patients from hospitals. So far, 1,300 patients have been discharged through that temporary effort, Delmolino said.

But much of the backlog remains: As of May, the last time the Massachusetts Health & Hospital Association issued a public report, 1,066 patients awaited discharge from 44 hospitals. Of that group, 672 were waiting for spots in nursing home beds, 105 for beds in long-term acute-care hospitals or inpatient rehabilitation facilities and 289 for home health services.

“The need has been so great for our hospitals to find placements for our patients,” Delmolino said. Despite the state’s efforts, “the number of patients who fall into that bucket continues to increase,” he said.

In Washington, patients are waiting three months on average to be discharged into a post-acute care setting, said Cassie Sauer, president and CEO of the Washington State Hospital Association. In extreme cases, they wait up to six months.

“We would have plenty of room if we could move these patients out. It would be like creating multiple new hospitals,” Sauer said.

Last year, Washington’s Department of Social and Health Services started offering $6,000 admission incentive payments to nursing homes and smaller payments to home health agencies to help transition patients out of hospitals.

But demand remains high, and the association is trying to get the Department of Social and Health Services and the Washington State Health Authority, which oversee Medicaid, to speed up their authorization process to approve patient stays in post-acute care settings.

Sauer understands the effect of the bottlenecks firsthand. Her father, who has Parkinson’s and dementia, was hospitalized in Texas during the pandemic with a head trauma caused by a fall. While he should have only been in the hospital for three to four days, he remained for nine during the search for a nursing home that could accept him, Sauer said. In the end, Sauer’s family ended up arranging home care services for him.

“The hospital needed the room,” she said.

Largest post-acute care companies, 2022

Visit Modern Healthcare Research & Data Center for more rankings, databases and surveys.