Reporting on why some patients are stuck in hospitals

By Yanick Rice Lamb

Patients typically complain about being released from the hospital sooner than they would like. I became intrigued when I heard about patients languishing in hospitals weeks and even months after being medically ready for discharge. This can happen to uninsured and underinsured patients who need long-term care.

Given the recent downturn in the economy, this could potentially happen to anyone who loses a job and the health coverage that came along with it. I wanted to write about the toll of delayed discharge on these patients, the health-care system and the general public.

When I heard about AHCJ’s Media Fellowships on Health Performance, I thought that delayed discharge would be an ideal topic. Preliminary research confirmed my belief. It was clearly an underreported topic. Information was fragmented and spotty at best.

In fact, once I was named one of the four fellows, fragmentation was a key theme throughout the 10 months of the program. I was focusing on a narrow slice of the population-the sickest, poorest and most invisible patients. However, this group is increasingly on the radar of hospital administrators who are being pressured to lower costs, raise profits and turn over beds. Although this group is small, it’s a costly segment of a hospital’s patient pool, because they are so hard to place into long-term care. Some patients have run up thousands of dollars – or even a few million – in unpaid medical bills.

Getting started

First, I had to wrap my brain around the problem and delve deeper into the finer points of Medicare and Medicaid. I also looked into hospital stays, overall discharge, insurance issues, uncompensated care, and transitions to long-term care at nursing homes, rehabilitation centers and residences. The Commonwealth Fund’s financial support of the fellowship allowed the Association of Health Care Journalists to supplement our individual research with customized seminars related to our special projects. We met a wide range of experts at these sessions and conferences. And, as fellows, we shared leads and supported each other throughout the program.

The challenge was finding the right data, the right patients and sometimes the right experts to connect the dots nationally. Some studies were outdated and/or told only a piece of the story. Sometimes discharge experts said they weren’t experts on my piece of the story. I found stats for this and stats for that, but pinning down the right combination of variables was challenging. Everyone acknowledged delayed discharge was a big problem, including the head of the Centers for Medicare and Medicaid Services. I thought CMS would be the answer to my statistical dreams, but the staff said they couldn’t deliver.

However, it’s easier to find such data on the state level in some cases. California is one of those states. With its large population and diversity, it’s a good microcosm of what’s happening nationally and the Office of Statewide Health Planning and Development was helpful. [See a webinar on how to analyze OSHPD data.]

An analysis of OSHPD’s hospital data showed a 30.8 percent increase in the length of stay for hard-to-place patients in California over a five-year period. Patients in the state’s Medicaid program (known as Medi-Cal), those on Medicare and the indigent averaged 18 hospital days in 2005 before being transferred to skilled-nursing and intermediate-care facilities. By 2009, their average length of stay was 26 days. That’s nearly five times the overall national figure. Over the past two decades, U.S. hospitals have reduced the average length of stay from 7.2 days in 1989 to 5.4 days in 2009, according to the American Hospital Association. [Chart]

Finding patients

Trying to put a face on these numbers was also a challenge. Like many reporters, I had difficulty finding patients to illustrate the story – the ones who make wonderful narratives. Sometimes a hospital or I would have a “Eureka” moment, but then it would turn out that the patient didn’t fit key criteria. Sometimes patients weren’t being discharged to long-term care. Sometimes they changed their minds. Sometimes someone dropped the ball. I encountered one patient who was stubbornly monosyllabic and another suffering from dementia.

Many hospitals were reluctant to make patients available, saying they were trying to avoid “preying on a vulnerable population.” On occasion, this sounded like an excuse or a bit patronizing, as if socio-economic status deemed a patient unfit for interviews. Most of the uninsured patients I met were struggling to make unruly financial ends meet. By and large they held their own in interviews, eager to share their stories to shed light on health-care challenges.

The eight-page package published in Heart & Soul, a national health magazine, opened with a round-up lead highlighting the delayed discharges of four patients. Then Montefiore Medical Center in the Bronx, N.Y., told me about Samantha Hawkins, who had a heart pump and multiple health conditions. After extended multiple stays, Hawkins had been discharged to skilled nursing care at her family’s nearby apartment. I rewrote the main piece, partially framed by Hawkins’ story. This time I kept the focus on the uninsured, spinning off other scenarios and other parts of the article into sidebars. I plan to continue updating and expanding the project, plus I have some multimedia and a ton of notes to incorporate.

The response to the package from readers, journalists, medical professionals and others has been great. We discussed it during a Twitter chat, or Tweetchat. My project was also cited in MuckReads, ProPublica’s “ongoing collection of the best watchdog journalism.”

Covering stories in your community

Discharge is a multilayered topic that’s ripe with story ideas that can be localized or examined nationally. Here are a few suggestions along with other ideas that popped up along the way:

• Find out if hospitals in your community have established teams to focus on complex discharges. These groups function as high-level SWAT teams that spring into action to resolve the most difficult cases with the lengthiest hospital stays. They often include the chief medical officer and a range of other top administrators who have the power to make decisions quickly. They might approve non-traditional housing arrangements, for example. Their solutions can be altruistic, but keep in mind that they’re also motivated by the bottom line.
• Ask about internal discharge studies. Some hospitals are doing more tracking and trying to go behind the numbers. You might still have to go hospital by hospital to determine how long patients stay beyond the time they’re deemed medically ready for discharge. In some cases, I watched people flip through clipboards to give me data.
• Talk to people on the frontlines of discharge. Many social workers, nurses, doctors and others have stories to tell, and they are eager to talk about the highs and lows of their work.
• Explore the ongoing debate on readmissions and the cost. Hospitals are under pressure to prevent them, but they complain that some readmissions are unavoidable and actually warranted. (Ironically, I witnessed an avoidable one when my mother was prematurely discharged and immediately readmitted while I was on the road visiting one of the dozen hospitals featured in this project.)
• Look into regulations as well as reimbursements. We hear lots of complaints about slow and low reimbursements from hospitals and nursing homes. Which complaints are warranted? Which ones could be eased with better practices and more efficiency? Some experts complain that nursing homes, in particular, find ways to work around regulations and game the system.
• Check out observational care. While some hospitals keep it in check, it can affect patients’ eligibility for long-term care if they don’t meet the three-day inpatient requirement for Medicare approval. Do patients know that they’re outpatients? Some don’t, patient advocates say.
• Assess the growth in primary-care delivery at hospitals as well as the transition of some doctors from private practice to hospital staffs. What does this mean for your community?
• Don’t believe the hype. For example, are immigrants really driving up health-care costs? Yes, there are some extreme examples (i.e., delayed discharge to a certain extent), but the numbers don’t always support the complaints.
• Keep an eye on the increase in the level of care required as people age. Some people are in worse shape at younger ages. What’s the future outlook?
• Get an idea of the availability of long-term care beds in your community. Are hospitals in your area expanding into long-term care? How much money are they making?
• Consider caregiving issues. Families are more fragmented, and they’re expected to do more in term of home care. They aren’t always ready, willing and/or available.
• Calculate the cost, financial and otherwise, of hospitals that close or cut services. How far do people have to go to be treated for trauma?
• Think about the potential impact of health-care reform on these issues. Will the problem of delayed discharges and care gaps change under Health Policy? When? At what cost?

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Yanick Rice Lamb, who teaches journalism at Howard University, is associate publisher and editorial director of Heart & Soul magazine. She reported this series while on an AHCJ Media Fellowship on Health Performance, supported by the Commonwealth Fund.