EXECUTIVE SUMMARY
The COVID-19 pandemic caused unprecedented bottlenecks in moving patients through the care continuum. But more patients are simply refusing to be discharged from hospital beds.
- Patients sometimes refuse discharge because of mental/behavioral health issues or problematic social determinants of health.
- Case managers and other healthcare professionals need to respect patients’ autonomy while also finding acceptable solutions for patients who remain in the hospital for days or weeks beyond medical necessity.
- Health systems can help prevent overstays by setting processes and policies that support case managers and physicians as they try to discharge problematic patients.
Patients who stay weeks or months in a hospital bed long after it is medically necessary are a major headache for case managers and providers.
They use up a resource that has become precious during the pandemic and nursing labor shortages. Their overstays raise ethical issues when patients admitted through the ED cannot receive adequate care in an inpatient unit.
A common reason hospitalized patients cannot be discharged is because they lack the health and social support to meet their post-acute care needs, researchers say.1
Many examples of this problem have occurred in the United States. But there are no standard solutions. Each hospital handles overstays differently, and some may allow such long-term patients to stay in the hospital indefinitely.
“This is universal,” says Maryanne Cassera, BSN, RN, ACM-RN, case management nurse at Providence Newberg Medical Center in Portland, OR. Cassera also is the president of the Oregon Chapter of the American Case Management Association (ACMA).
Long-term patients were a problem even before the COVID-19 crisis caused bed shortages across the country. “Case managers are unique,” Cassera says. “We really need to be creative in solving the problem.”
Cassera recalls a patient who refused to leave the hospital because no one was available to take care of her cat if she stayed in a nursing facility. She also was trying to apply for Medicaid. These obstacles led to the patient staying in the hospital for more than three weeks, longer than medically necessary.
At first, Cassera could not find placement for the patient and her cat. But she finally solved the discharge problem. “Eventually, I found a care home in her town that would take the cat, too.”
In another case, publicized in a Florida newspaper in 2017, a patient was medically cleared for discharge a few weeks after admission. He needed medical supervision at home or at a long-term acute care (LTAC) facility, but the family refused to take him home or to place him in the LTAC. After contacting more than 600 LTACs and covering the patient’s daily costs when insurance stopped paying the man’s bills, the hospital took the rare step of suing to evict the patient.2
Ethical Challenges
Patient safety and the ethics of discharging patients against their will are challenges. In one tragic case in 2018, a homeless man refused to leave an Oklahoma hospital after he was discharged. The patient was arrested for trespassing and died shortly after he was sent to jail.3
In a more recent case, a 38-year-old man remained at a medical center for more than five months, despite the staff trying to discharge him the day of his arrival. He was a social admission to the hospital’s Comprehensive Psychiatric Emergency Program and presented with no acute medical needs. Even as the hospital was filling beds because of COVID-19, the man refused to sign discharge papers. Hospital staff said he was able to make medical decisions, and was diagnosed with chronic pain, behavioral issues, depression, and narcissistic personality disorder.4
Medical ethicists view these cases differently than hospital leaders because they do not consider the economic costs of a long and unnecessary length of stay.
“One of the lenses we bring to this is related to trying to respect the patient’s autonomy and see what that looks like here,” says Trevor Bibler, PhD, MTS, assistant professor at the Center for Medical Ethics and Health Policy at Baylor College of Medicine. “If medical decisions are shared, then it’s a conversation amongst healthcare professionals and patients to find out what’s best. Sometimes, that means giving people a little more time to make a decision.”
Hospitals can take measures to prevent patients from refusing discharge. “At my institution, we have a good track record of getting our administration involved early and figuring out what the patient’s goals are and if they can be met at another place,” Bibler explains. “It’s most important to have a process and policy in place, and the purpose of the policy is to get institutional buy-in.”
The goal is to treat everyone fairly. This means parameters should be in place to consider the need of the hospital to care for the entire community and not just a single patient.
“Having a process gives the institution and individuals at the bedside institutional support for saying, ‘This is what’s going to happen, and we will discharge you from this institution at the end of this time frame,’” Bibler explains.
These policies could prevent the hospital from taking an extreme action, such as using real estate domicile laws to push patients to leave a hospital bed. (See Q&A story in this issue on ethical decisions for patients who refuse to leave.)
“It’s unfair to bedside professionals to have to deal with this,” Bibler says.
When institutions create policies to handle difficult discharges, case managers and bedside staff are more at ease because the process is not entirely their responsibility.
Obstacles to safe and timely discharges have increased with the pandemic’s decimation on staffing at hospitals, skilled nursing facilities, and other healthcare entities. An estimated half-million people have left healthcare work since March 2020, according to U.S. Department of Labor data.5 Many of the people leaving are seasoned nurses. There is a huge experience gap with new nurses.
“There’s a distinction between not wanting to leave and not being able to leave because there is no place to go,” Cassera explains. “These patients often are complex medically, with a lot of comorbidities, and they’re very tight on beds at the skilled nursing facility level.”
If the hospitalized patient is morbidly obese, the placement problem is compounded. “It’s very challenging to find a place to accommodate a two-person transfer,” she adds.
More LTAC staff left the workplace to avoid COVID-19 vaccine mandates. “The healthcare community lost a lot of caregivers because of the vaccine mandate, including nursing assistants, lay caregivers, physical therapists, nurses, and ancillary services,” Cassera explains. “One care center said, ‘We have plenty of beds, but no staff.’”
LTACs, Others Face Capacity Issues
Small care homes, LTACs, skilled nursing facilities, and other post-acute inpatient organizations have experienced unprecedented capacity problems.5 Case managers must be creative and persistent to find those needed beds. Some states have devoted resources to reduce the transition of care bottleneck. For instance, Oregon has paid for a skilled nursing facility unit to help establish COVID-19 recovery units for patients from hospitals and LTACs. The Oregon Department of Human Services also created a team to help hospitals find places for patients in LTACs or adult care homes.6
Adult care homes are private facilities funded privately or by Medicaid. They employ one or two caregivers for 24 hours, who assist with activities of daily living, cooking, and cleaning. These sites typically receive less funding than much larger LTACs, and they often do not have the staff and equipment to handle more physically and cognitively challenging patients. For example, a morbidly obese patient with dementia who is at risk of wound infection could be too challenging for an adult care home to handle.
“I had one patient who was very challenging. She had advanced dementia and was picking at her wounds,” Cassera says. “She was morbidly obese and needed to be turned over for wound care, but she was scared of turning, and it took three or four people to turn her.”
Case management’s goal was to establish rapport with the patient and wean her off the three to four caregivers so one or two people could handle their turning and wound prevention care.
“That’s the value of case managers,” Cassera says. “We get adjustments in medication and help the nursing staff be more comfortable with managing the obese patient.”
Hospital leadership can support case management with flexibility in length of stay goals, particularly during a crisis period.
“What if the CEO says, ‘We’ve been on your case about length of stay; let’s put the brakes on it and not talk about it until after we talk with the patient about what her values are,’” Bibler says. “It helps to have administrative support, saying, ‘OK, let’s understand the situation you’re in.’”
That type of support and flexibility can go a long way to reduce staff distress over patients who refuse to accept discharge.
Case managers also can learn more about how post-acute settings are paid and advocate for adequate reimbursement when patients need more resources than is standard. They also can help patients transition to hospice care or receive behavioral health support, as needed.
“It’s definitely an art, and case managers are just unique in their practice,” Cassera says. “We need clinical understanding of nursing and medical staff, but we also look at this as trying to think of the long-term goal. We’re the quarterback of the team.”
REFERENCES
- McGilton KS, Vellani S, Krassikova A, et al. Understanding transitional care programs for older adults who experience delayed discharge: A scoping review. BMC Geriatr 2021;21:210.
- Gluck F. Lee Memorial Hospital sues to evict patient refusing discharge to nursing home. The News-Press. July 31, 2017.
- Rock A. Discharged patient arrested for refusing to leave hospital dies in jail. Campus Safety. Jan. 30, 2018.
- Lakamp P. Medically cleared patient ‘refuses to leave’ ECMC for 150 days. The Buffalo News. May 13, 2020.
- Bodine J. The nursing shortage — a healthcare crisis — February 2022. Association for Nursing Professional Development.
- Terry L. Hundreds still languish in Oregon hospitals, waiting a place to go for continued care. Oregon Capital Chronicle. Nov. 30, 2021.
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